Maintaining balance : the physical therapy workforce in North Carolina in the year 2000 : report of the Technical Panel on the Physical Therapy Workforce

Maintaining Balance:
The Physical Therapy Workforce
in North Carolina in the Year 2000
REPORT OF THE TECHNICAL PANEL ON THE PHYSICAL THERAPY WORKFORCE
Presented to:
THE COUNCIL FOR ALLIED HEALTH IN NORTH CAROLINA
May, 2000
The Physical Therapy Workforce
Assessment Project is a joint effort of:
The Council for Allied Health in North Carolina
The North Carolina Area Health Education Centers Program
The Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill
Practitioners
Jan Gwyer, PT PhD
Department of Physical Therapy
Duke University Medical Center
Box 3965Durham, NC 27710
919-681-4381
Eileen Watkins, PT
President, NC PTA
CompRehab of Wilson
1811 Forest Hills Road
Wilson, NC 27893
252-243-7400
crwwilson@aol.com
Cathy Smith, PT
Department of Physical Therapy
Wake Medical Center
3000 New Bern Ave
Raleigh, NC 27610
919-852-3500
cathy.smith@wakemed.org
Carolyn Cusic, PT
NC Association for Home Care
908 Grove Street
Chapel Hill, NC 27514
(919) 929-5537
carolyncu@aol.com
Employers
Jim Sawyer
Summit–Inn at the Ridge
100 Riceville Rd.
Asheville, NC 28805
828-299-1110
Joan Evans, PT, MBA
Vice President, Moses Cone Memorial Hospital
1200 North Elm Street
Greensboro, NC 27401-1020
(336) 832-8243
joan.evans@mosescone.com
Ron Covington,
Medical Facilities of North Carolina
1300 S. Mint St. Ste. 201
Charlotte, NC 28203
704-338-5855
Educators
Katherine White, PT, PhD
Dept. of Physical Therapy
Western Carolina University
Cullowhee, NC 28723
(828) 227-2191
kwhite@wcu.edu
Darlene Sekerak, PT, PhD
Division of Physical Therapy
Dept. of Allied Health Sciences
CB #7135, Med School Wing E
University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7135
919-843-8660
dsekerak@css.unc.edu
Stephen Bailey, PT, PhD
Dept. of Physical Therapy
Campus Box 2085
Elon College
NC 27244-2010
(336) 538-6853
baileys@elon.edu
Workforce Planning Experts
Jackie Keener, PhD
Labor Market Information Division
NC Department of Labor
700 Wade Ave.
Raleigh, NC 27611
919-733-2936
Keener.Jackie@esc.state.nc.us
Ben Massey, PT
NC Board of PT Examiners
18W Colony Place, Suite 120
Durham, NC 27705
bfmassey@mindspring.com
Karen Haas, PT, MPH
NC Department of Health and Human Services
943 Washington Square Mall
Washington, NC 27889
(252) 946-6481 ext 293
Facilitators and other Attendees
Robert Thorpe, EdD, RT
Allied Health Sciences
UNC-CH, CB#7120
Chapel Hill, NC 27599-7120
(919) 966-2343
bthorpe@med.unc.edu
Alan Brown, MSW
NC AHEC Program
UNC-CH, CB#7165
Chapel Hill, NC 27599-7165
(919) 966-0814
albr@med.unc.edu
Thomas Konrad, PhD
Cecil G.Sheps Center for Health Services
Research
UNC-CH, CB#7590
Chapel Hill, NC 27599-7590
(919) 966-7636
bob_konrad@unc.edu
Samruddhi Thaker, MHA
Sheps Center for Health Services Research
UNC-CH, CB#7590
Chapel Hill, NC 27599-7590
(919) 966-4505
sthaker@email.unc.edu
Rees Jenkins, MBA
NC Health Care Facilities Association
Director, Policy Development
5109 Bur Oak Circle
Raleigh, NC 27612
(919) 782-3827
reesj@nchcfa.org
North Carolina Physical Therapy Workforce Assessment Technical Panel
Panel staff: Thomas Konrad, Johanna Ames, Carolyn Busse,Jean Cox, Erin Fraher, Tonya Jenkins, Michael Pirani, Jeff Rosenthal, Thomas Ricketts, Laura
Smith, Samruddhi Thaker and staff at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.
Acknowledgements: The panel members would like to thank the North Carolina Area Health Education Centers, The Cecil G. Sheps Center for Health
Services Research and the Council for Allied Health in North Carolina for their vision for conducting this panel process. The study has been made possi-ble
by the financial support of the North Carolina Area Health Education Centers Program.
Executive Summary
Background
A proposal to establish an advisory panel to examine the
status of various North Carolina allied health professions was pre-sented
by The Cecil G. Sheps Center for Health Services Research
to the North Carolina Area Health Education Centers Program
(NC AHEC) and the Council for Allied Health in North Carolina
(Council) in March 1999. The purpose of the advisory panel
process was to review the best available statistical and administra-tive
data, to discuss existing and emerging policies, and to con-struct
a consensus statement on the need for, and supply of, allied
health professionals by selected disciplines in North Carolina. The
process was approved and designed as a collaborative effort by the
representatives of the Cecil G. Sheps Center for Health Services
Research, the Council and the NC AHEC. The process envisioned
a series of panels comprised of stakeholders including practition-ers,
employers, educators, and workforce planning experts for
each allied health profession. Physical therapy was selected as the
first profession under review and this document reports the
results of the consensus process.
A physical therapy panel was convened on November 17,
1999. The task before the panel was to address one overarching
question: “What is the overall balance between supply and require-ments
for physical therapists (PTs) and physical therapist assistants
(PTAs), and how is it likely to change given current trends?” Relatively
good data describing the supply of PTs and PTAs are available
through the North Carolina Health Professions Data System
(HPDS) maintained by the Cecil G. Sheps Center in collaboration
with the NC AHEC. These data provided the basis for the panel’s
examination of historic trends in the supply of PTs and PTAs.
Historically, the physical therapy occupation in North
Carolina has been believed to be in either a shortage or balance
situation when compared with the demand for physical therapy
services. Several indicators including the ratio of PTs per popula-tion,
the number of applicants for the employment positions, and
the reports of educational program directors, and growing salaries
have supported this belief. More recently, anecdotal reports of cut-backs
in hours and employment for physical therapists have
become widespread since the phase in of changes to the Medicare
program in the long-term care and rehabilitation systems required
by the Balanced Budget Act (BBA) of 1997. Although systematic
data were not always available or analyzed to quantify or validate
these views, the panel process undertaken as part of the collabora-tive
effort was able to systematically analyze and evaluate the PT
workforce situation in North Carolina.
Based on the data analyzed by the advisory panel and pre-sented
at length in this report, the panel makes the following rec-ommendations:
Recommendations
SUPPLY and EDUCATION
The panel concludes that supply and requirements in the
physical therapy professions are in approximate balance at this
time and recommends the following courses of action to educa-tional
institutions in North Carolina preparing physical therapy
personnel:
• Maintain the status quo with respect to the number of pro-grams
and the number of enrollments in physical therapy and
physical therapist assistants in North Carolina’s PT and PTA
programs. Follow the APTA suggested moratorium on any
new programs through 2003.
• Address the issue of under-representation of minorities in
physical therapist and physical therapist assistant programs in
North Carolina.
• Educational policy makers should avoid downsizing or clos-ing
programs in response to a single year’s decline in the
applicant pool or graduates’ employment opportunities.
Doing so might waste resources if demand resurfaces while
the capacity to produce new personnel is eroded. Hence, the
panel recommends that those few programs experiencing
declining enrollments should receive continued support for a
minimum of 3 to 5 years as local, state and national trends
can be observed and interpreted.
DISTRIBUTION
The panel acknowledges that geographic disparities in the
availability of physical therapy personnel exist throughout the
state and recommends the following policies:
• Continue to assess trends in geographic disparities but aug-ment
this information with more focused assessment of the
nature and extent of employment opportunities for graduates
that are available both in rural and in health professions
shortage areas.
• Oppose legislative initiatives which might inhibit patients
from having direct access to physical therapy practitioners
because such efforts might well discourage PT practice in
physician shortage areas.
DIVERSITY
The panel recommends that representatives of a diverse
community of stakeholders from the educational, professional,
regulatory, and employer communities should meet to frankly
address the lack of diversity in North Carolina’s PT workforce and
assess what specific strategies can be designed and implemented
to enable the ethnic composition of NC PT and PTA workforce to
more closely approach that of North Carolina’s general population.
The agenda of this group should include efforts to:
• develop an effective strategy to monitor admission, matricula-tion,
graduation, and initial employment data at both PT and
PTA programs for their size and diversity;
• monitor shifts in affirmative action policies affecting the
health professions at the national and state level;
• enlarge and develop the applicant pool and foster the recruit-ment
and retention of minority candidates to PT and PTA
educational institutions;
• assure that there are adequate employment opportunities for
minority physical therapists and physical therapist assistants,
especially in health professions shortage areas; and
• assess the success of educational programs in historically
minority colleges and universities and in other post-second-ary
education locations in the recruitment and retention of
minority students.
WORKFORCE SURVEILLANCE
The panel recommends that the following activities be
undertaken by the panel itself and other partners in the Allied
Health community.
Convene the expert panel annually to analyze workforce
supply data using a three-year time horizon. The timing of this
meeting should be determined in consultation with AHEC person-nel,
the Council, educational program directors, and the licensing
board. It should be strategically timed, late enough in the “licens-ing
cycle” to acquire and analyze latest available workforce data,
but early enough in the “educational planning” cycle to provide
meaningful input into that process. In addition, the panel recom-mends
that in the interim a regular one-hour time be scheduled
every three months for an optional meeting at which panel mem-bers
can share information and updates on PT/PTA workforce
issues via a conference call.
The panel endorses efforts by the licensure board, the Cecil
G. Sheps Center for Health Services Research, and NC AHEC to
enhance the collection and analysis of data on several crucial
workforce supply issues. These issues include changes in the over-all
supply of licensees, the number residing and the number
working in the state. The panel encourages these organizations to
work together to focus attention on transitions involving attrition
from, and accessions to, the physical therapy workforce. The
panel will work with these organizations to develop a specific data
analysis protocol to facilitate year to year comparisons of the over-all
supply of workforce and of key transitions in the workforce
supply. To facilitate interpretation, the panel recommends that this
protocol once developed be applied retrospectively to the previous
three years’ data to facilitate five-year forward projections. Key
elements in that protocol should include:
• attrition measured in terms of: (a) withdrawals from
licensed practice (b) retirements;
• accessions broken down by: (a) in-migrants previously
licensed in another state; (b) initial licensees in NC coming
from out of state educational institution; (c) initial
licensees in NC coming from in-state program.
The panel endorses ongoing efforts to monitor geo-graphic
trends in supply including county level ratios,
under-representation of minorities, urban versus rural differ-ences,
and AHEC regions. The panel endorses ongoing
efforts to monitor the requirements for physical therapy per-sonnel
insofar as possible both in terms of need and
demand and recognizes that need is likely to be relatively
stable while demand can be quite volatile. Need is largely
driven by slowly varying and relatively predictable underly-ing
demographics and disease patterns, while demand can
shift quickly depending on scope of coverage and reim-bursement
levels, and administrative decisions.
The panel recognizes both the utility of periodic sur-veys
of employers about demand for selected allied health
professionals and the costs and challenges that such data
collection efforts involve. It will explore the feasibility of
more selective and efficient survey mechanisms in subse-quent
annual meetings.
I. Background
1.1 THE PHYSICAL THERAPY WORKFORCE IN TRANSITION
For the 10 year period from 1996 to 2006, the US Bureau of
Labor Statistics has predicted that the supply of physical thera-pists
in the United States will increase from 115,000 to 196,000
and that physical therapist assistants will increase from 84,000 to
151,000. Despite these predictions, this strong growth may not be
realized due to changes in the way in which physical therapists
are reimbursed and because of changes in federal health insurance
programs. Anecdotal reports of cutbacks in hours and employ-ment
for physical therapists have become widespread since the
phase in of changes to the Medicare program in the long-term
care and rehabilitation systems required by the Balanced Budget
Act (BBA) of 1997. Because private insurers often follow
Medicare’s lead in coverage limitations and service exclusions, the
BBA provisions may have wider implications for the financing of
physical therapy and related services. Specifically, according to an
employment survey released in December, 1999 by the American
Physical Therapy Association (APTA), physical therapists who
work in skilled nursing facilities (SNFs), home health settings,
and in private practice continued to experience job losses, salary
cuts and reductions in practice hours. However, this survey
reported an unemployment rate of 3.2 percent, which was up just
slightly from the 3 percent unemployment rate reported in an
April 1999 APTA survey. There have been anecdotal reports by the
directors of educational programs for physical therapists and
physical therapist assistants about declines in employment
prospects for recent graduates.
More recent developments may have also affected the out-look
for physical therapy nationally. On November 9, 1999,
Congress passed the Balanced Budget Refinement Act (BBRA) that
mandates a two-year moratorium on the $1,500 Medicare pay-ment
cap on physical therapy and other rehabilitation services
which was included in the BBA of 1997. This new legislation was
signed into law on November 29, 1999 with an implementation
date of February 1, 2000. This law increases payment for services
provided in skilled nursing facilities to patients who have medical-ly
complex conditions; it also delays a previously scheduled 15
percent cut in payment for home health services until one year
after the implementation of a prospective payment system (PPS).
This development is likely to result in some improvement in the
outlook for the profession in the very near future. A notice in the
Federal Register [April 11, 2000] made it clear that physical thera-py
services are not part of the outpatient hospital PPS and that
Medicare will continue to pay for physical therapy services under
the fee schedule in all settings. This rule becomes effective in
October 2000. The PPS for rehabilitation hospitals is scheduled
for implementation on April 1, 2001 and is likely to affect the
physical therapy profession.
Despite the concerns associated with federal payment policies,
recent assessments of the balance between supply and requirements
for physical therapy occupations have either assumed labor short-ages,
a balanced employment situation, or only a slight labor sur-plus.
However, the possibility of a significant decrease in demand
for physical therapy services provides an important context in
which to focus attention on the physical therapy workforce. It is
possible that reductions driven by national reimbursement policies
may reverberate through local employers and may lead to underem-ployment
or unemployment of physical therapy personnel.
This possible scenario was an important consideration moti-vating
various stakeholders to approach the Council for Allied
Health in North Carolina and ask that a study be conducted to
assess the physical therapy workforce in the state.
1.2 THE ALLIED HEALTH WORKFORCE PLANNING PROCESS
A proposal to establish an advisory panel to examine the sta-tus
of various North Carolina allied health professions was pre-sented
to the North Carolina Area Health Education Centers
Program (NC AHEC) and the Council for Allied Health in North
Carolina (Council) in March 1999. The purpose of the proposed
panel process was to review the best available statistical and
administrative data, discuss existing and emerging policies, and to
construct a consensus statement on the need for, and supply of,
allied health professionals in selected disciplines in North
Carolina. The process was designed to take place under the joint
guidance of representatives of the Cecil G. Sheps Center, the
Council for Allied Health in NC and the Area Health Education
Centers Program. The process envisioned a series of panels com-posed
of representatives from various stakeholder groups.
Stakeholders included practitioners from the allied health profes-sions,
as well as employers, educators, and workforce planning
experts. Panels would be constructed to address the specific situa-tion
of different allied health professions over an extended time
period. The NC AHEC and the Council approved this proposal for
Allied Health in NC on April 27, 1999. Subsequently, the Council
for Allied Health in NC members debated which professions
would be selected for study over the next three years. Physical
therapy was selected as the first profession.
1.3 PHYSICAL THERAPY WORKFORCE TECHNICAL PANEL:
SCOPE OF WORK
A panel consisting of educators, practitioners and employers
was convened on November 17, 1999. The task before the panel
was to assess the employment conditions of physical therapists
and physical therapist assistants in the state of North Carolina. A
number of questions were raised:
• Are PTs and PTAs facing the same situation in North Carolina
as in the rest of the country?
• How well are the physical therapy needs of the North
Carolinians being met?
• Have the employment prospects of physical therapy person-nel
been reduced?
These questions can be subsumed under one general question:
What is the overall balance between supply and requirements for
physical therapists and physical therapist assistants, and how is it likely
to change given current trends?
At the state level, where educational and workforce policy
meet, one of the key issues involves answering the question: “Are
we producing too many, too few, or about the right number of
physical therapists and physical therapist assistants to meet cur-rent
and future requirements?”
Although the overall balance between supply and require-ments
is a paramount workforce issue, other concerns are equally
important. For example, some issues, such as staffing shortages,
recruitment and retention difficulties, and underemployment of
physical therapists and physical therapist assistants may be more
relevant for certain areas of the state or for certain specific stake-
holder groups. This is the case because North Carolina is a diverse
state with extensive geographic and demographic variability.
Concerns with distribution and diversity raise the following ques-tion:
“Are some areas of the state or population groups more
prone to experience certain kinds of labor imbalances such as
staffing shortages, recruitment and retention difficulties, or under-employment?”
The goal of this collaborative project was to examine the
forces affecting employment for physical therapists and physical
therapist assistants in North Carolina. The primary strategy was to
build the project on accepted workforce analysis methods and to
use the best available data to address the above questions. This
consensus statement is based on the data analysis and panel dis-cussion
concerning the current and likely future balance of supply
and requirements for physical therapists and physical therapist
assistants in the state of North Carolina.
The remainder of this report examines national trends in the
physical therapy workforce, provides background on the North
Carolina situation, describes the information and data sources that
the panel used, reports the panel’s findings and conclusions, and
ends with the panel’s recommendations.
NATIONAL TRENDS
In 1997, the APTA commissioned a workforce study
from Vector Research, Inc. to look at the employment prospects of
PTs and PTAs through the year 2020. Their methodology included
the examination of salaries and job vacancy rates and interviews
with program directors in educational institutions, recruiters, state
APTA representatives, researchers, and practicing PTs and PTAs.
Vector’s supply projections accounted for US and interna-tional
new entrants, deaths, retirements, and part-time labor force
participation. The demand forecasts used age-, sex-, and insur-ance-
adjusted per capita staffing models that reflect the current
paradigm of population-centered health care planning. The model
also incorporated factors such as the aging of the population,
long-term economic growth, and increased HMO penetration.
Finally, increased competition from other health care providers
(chiropractors, athletic trainers, and occupational therapists) was
also considered.
The Vector study projected that a national shortage of quali-fied
PTs would continue through 1998, at which point equilibri-um
would occur. By the year 2000, they projected a slight sur-plus.
According to this scenario, physical therapists would still be
able to find employment, but not in their most preferred employ-ment
setting or geographic location. The Vector Study projected
that new entrants into the field would increase due to both an
increasing number of educational programs and an in-migration
of foreign-educated PTs. Not until 2005 would there be a notice-able
decline in employment opportunities marked by lower real
compensation, lower rates of labor participation, and declining
enrollments in educational programs. A surplus of PTs on the
order of 20-30 percent would exist by 2005-2007.
On the supply side, Vector used conservative estimates of
new educational programs that yielded average annual increases in
new entrants of slightly more than 5 percent for PTs and 12 per-cent
for PTAs at the national level. On the demand side, PTs and
PTAs typically serve an older patient population that provides a
source of reimbursement at the most favorable rates. Vector
assumed that competitors such as chiropractors, occupational
therapists and athletic trainers would maintain a market share
similar to their current share. Technology would have a negligible
effect on the demand. They also stated that the demand for PTs
may decrease due to increased use of PTAs. Demand for PTs was
projected to decrease by 3 percent between 1995 and 2005.
Vector projected that demographic and economic factors
would each affect demand: an aging population would account for
a 12 percent increase and economic growth would account for an
additional 12 percent increase. The Vector study assumed that
growth in demand would be lessened through expansion of the
“California model” of managed care. This “California model” sug-gests
that managed care firms will lower expenses by limiting
patient visits to health professionals, in this case PTs and PTAs.
This service delivery policy was expected to account for an antici-pated
17 percent decrease in demand, while the substitution of
PTAs for PTs accounts for an additional 10 percent decrease in
demand for PTs. Taken together, Vector’s scenarios anticipated that
new demand for PTs or PTAs would be concentrated among ‘sec-ond-
choice’ settings like home health and nursing homes. The
introduction of the Balanced Budget Act of 1997 (subsequent to
the Vector Study) may change the applicability of this scenario. It
appears that underemployment (i.e., part-time personnel who
report working fewer hours than they want to) may actually be a
special characteristic of PTs and PTAs employed in skilled nursing
facilities and home health care settings.
Additionally, in the area of physical therapy educational pro-grams,
the Doctor of Physical Therapy (DPT) — a post baccalau-reate
degree offered upon successful completion of a doctoral-level
professional (entry-level) or a post-professional “transition” educa-tion
program– has recently been the focus of numerous questions
and concerns by physical therapists. Throughout the US, as of
April 1, 2000, eight professional DPT programs are accredited, 19
BSPT (Bachelors) or MPT (Masters) programs are making the tran-sition
to the DPT, and 3 institutions are developing professional
DPT programs.
As health care delivery becomes a global enterprise, both for-profit
and nonprofit organizations are making health care available
to people in developing and transitional countries in Africa, Asia
and Latin America. Globalization of the employment market is
likely to increase employment opportunities for physical therapists
and physical therapists assistants outside the United States and is
expected to affect the supply and demand scenario in the long run.
Finally, there has been an emerging interest in the area of
evaluating effectiveness of physical therapist interventions at the
national level. This interest is reflected by the six one-year research
grants awarded by the Foundation for Physical Therapy Board of
Trustees to fund research projects to evaluate the effectiveness of
physical therapist interventions in different practice areas.
II. The North Carolina Situation
Historically, the physical therapy occupation in North
Carolina has been believed to be in either a shortage or balance
situation when compared with the demand for physical therapy
services. This belief was supported by several indicators. First, the
supply of therapists per population has been below the national
average. Further, the number of applicants has far exceeded the
positions available, and the reports of physical therapy program
directors have consistently indicated that virtually all of their
graduates were being employed or seeking additional education.
Growing salaries and widespread reports that employers were
seeking to fill positions buttressed this widely shared belief,
although systematic data were not always available to quantify or
validate these perceptions.
Relatively good data describing the supply of PTs and PTAs
are available through the North Carolina Health Professions Data
System (HPDS). The HPDS is maintained by the Cecil G. Sheps
Center in collaboration with the North Carolina Health Education
Centers Program and contains data on many of North Carolina’s
licensed health professionals. The HPDS data facilitated the panel’s
ability to examine historic trends in the supply of physical thera-pists
and physical therapist assistants with a relatively high level
of precision. Early in the panel’s deliberations, panel members
realized that efforts to assess demand or requirements for PT serv-ices
are not very precise, and may require more sustained data
collection or the definition of more explicit assumptions. Existing
data in North Carolina’s license files report the settings in which
PTs and PTAs in North Carolina are currently working. These set-tings
include hospitals, nursing homes, home health agencies,
rehabilitation centers, physician offices, school systems, private
and contract practices, as well as faculty positions in educational
institutions. However, these data do not specify whether person-nel
are part or full time workers in these settings. The most recent
license renewal data collected in 1999 by the North Carolina
Physical Therapy Board contains this information and will prove
helpful in future workforce monitoring efforts. Unfortunately,
these 1999 data were not available to the panel during its deliber-ations
and therefore could not be included as part of supporting
evidence for this consensus statement.
One of the advantages of having licensure data is that infor-mation
is available on PTs and PTAs who are classified as inactive
within the state. It can also be ascertained year to year who does
not renew their license and thus, the supply numbers can be
adjusted with more precision. Because this workforce is a relative-ly
young one, it is not expected that retirements will be a major
factor in projecting the size of the workforce in the near term. It is
not presently known how extensive mid-career temporary with-drawal
is present among the physical therapy workforce, or how
frequently inactive PTs living in NC return to the workforce. Both
longitudinal analyses of licensure data, and ongoing work by
members of the panel in this area will be helpful in monitoring
the supply and demand of physical therapy professions. Analyses
of the most recent data from the NC licensure renewal form for
2000 is not reflected in this study.
Because the assumptions on the supply side of the Vector
study were either unstated or not applicable to North Carolina, we
chose a comparative approach. This involves benchmarking the
supply and requirements balance against national ratios. The first
order measure of “requirements” is a comparative practitioner-to-population
ratio where the primary standard is the national practi-tioner-
to-population ratio as defined by the APTA’s latest available
data. This ratio was compared to the North Carolina practitioner-to-
population ratio which was determined using the HPDS data.
Data from the HPDS files were analyzed at the Sheps Center dur-ing
June– November 1999 and a preliminary statement on the
state of physical therapy profession was drafted and disseminated
to members of the panel in March 2000.
2.1 THE CONTRIBUTION OF NORTH CAROLINA’S EDUCATIONAL
INSTITUTIONS TO THE OVERALL SUPPLY OF PHYSICAL
THERAPY PERSONNEL
A key issue for workforce planning in North Carolina relates
to the extent to which policies under the control of the state can
affect the size, composition, and distribution of the health care
workforce. The primary impact that state policy makers can have
on these factors is through support for educational institutions.
Consequently we have devoted a substantial portion of this report
to the discussion of this topic.
To understand the relationship between the output of North
Carolina’s educational institutions and new entrants in the work-force,
we have calculated an indicator called the “retention factor.”
This index is simply the proportion of graduates of schools locat-ed
in North Carolina who have obtained a license, kept that
license for one year, and who currently have a mailing address in
this state. For PTs statewide, the overall retention factor is about
0.54. This means that only slightly more than half of the PTs
trained in the state’s educational institutions can be expected to
enter the North Carolina PT workforce.
However, as can be seen from Exhibit 1, the retention factor
differs substantially by school and program. Private schools (e.g.,
Duke) tend to recruit a larger proportion of their applicants from
out of state and disperse these graduates quite widely geographi-cally.
The retention factor for Duke’s master’s degree program for
the 1998 graduating class was 0.17, meaning that only 17 percent
of those graduates are currently in the NC workforce. Studies of
employment of recent graduates in NC and adjoining states are
currently being conducted by Dr. Jan Gwyer and promise to yield
more information about this process.
The master’s degree programs at the three large state
schools– East Carolina University (Greenville), University of North
Carolina (Chapel Hill) and Western Carolina University
(Cullowhee) most likely recruit a larger proportion of in-state stu-dents
than programs at private colleges and universities. A rela-tively
uniform proportion of the graduates of each of these pro-grams–
almost 60 percent– enters the North Carolina workforce.
The retention profile of the state’s only bachelor’s level program,
Winston Salem State, is somewhat higher, with about 82 percent
of the school’s 1999 graduates entering in the North Carolina
workforce. Although the graduating class of this program is quite
small, its actual capacity exceeds the number graduating in recent
years. Because of the new requirement for postgraduate education,
the future contribution of this institution to the NC PT workforce
assumes that the proposed Master’s degree program will receive
provisional accreditation shortly and that 70 percent of 20 esti-mated
graduates will stay in state. This estimate is based on the
fact that 7 of the 10 students already admitted to that program are
North Carolina residents. Finally, we have included a projected
graduation class of 44 in our estimates from the state’s newest PT
program located at Elon College. We project that 15 of those grad-uates
(34 percent) will remain in state based on an informal poll
taken by the director of Elon College’s PT program. Our projec-tions
assume that the class size will remain constant for all these
programs.
This profile of the state’s graduates should be placed in the
context of the entire PT workforce. Historically, the growth of
North Carolina’s PT workforce has resulted more from in-migra-tion
than from production of graduates from the state’s schools.
Over the last decade, the average net annual growth in PTs has
averaged about 165 per year, but, assuming our retention figures
are correct, only about 66 per year of these new additions have
been due to production of graduates from the state’s schools. This
latter figure comes from applying the aggregate retention factor
(0.54) to the average of the 1996 and 1997 graduates. We do not
have graduation or retention figures before this period.
Although less than half of all new additions to the North
Carolina PT workforce are coming from in-state schools, the over-whelming
majority of that 50 percent are coming from the four
state-supported schools. Consequently, this is the place where
state-initiated activity might have its greatest impact on the PT
workforce. Comparison of the 1998 licensure file to the 1997 file
suggests that new licenses were granted to 317 individuals with
NC mailing addresses. Of these, only 81 were graduates of NC
schools, which is a number consistent with our expectations using
the data provided by the NC PT Board. However, the relatively
large number of new entrants into the state, compared to the
overall historic trend may need further examination. More analysis
of year-to-year differences in attrition and out-migration would be
worthwhile. It is not possible to compare 1999 addresses to 1998
addresses, because the 1999 data file is not yet available.
When the same type of analysis is applied to the physical
therapist assistant workforce, we find that the overall retention
factor is in the range of 0.75 (see Exhibit 2). Thus unlike physical
therapists, most of this growth has occurred as a result of the
activities of in-state educational institutions, mostly the publicly-supported
community college system. There are currently 8 wide-ly
dispersed community colleges that are educating PTA’s in two-year
programs; most of these typically accept a new class each
year. The total output of these programs has typically been about
100 to 120 graduates per year for the last four years. The Guilford
Technical Community College started in fall 1998 and is the most
recent PTA program. It offers training in cooperation with 7 other
community colleges and reserves slots for each of these colleges.
Further, since a high proportion of these individuals enter the NC
workforce, net additions to the workforce from in-state technical
and community college programs are in the range of 90 to 95 new
PTAs. One school, Fayetteville Technical Institute and Community
College located near a large military base, has approximately 54
percent of individuals who enter the NC workforce.
2.2 TRENDS IN PERSONNEL SUPPLY: PHYSICAL THERAPISTS
The growth in the number of physical therapists in the state
has been substantial over the last 20 years. North Carolina had
only 677 active physical therapists in 1979; a decade later that
number had almost doubled to 1,335, while by 1998 there were
2,815 PTs active in the state. Similarly, Exhibit 3 displays growth
in the ratio of PT per 10,000 population which has been substan-tial
and has increased over the last decade. In 1989 there were 2
PTs for every 10,000 persons in North Carolina. By 1998 this
ratio had become 3.7, approximating the national rates. According
to data from the American Physical Therapy Association, the
national ratio of PTs per 10,000 population has stabilized between
4.0 and 4.9 over the last decade, after a period of substantial
growth in the 1980s. Thus, North Carolina’s current ratio of about
1 physical therapist for every 2,700 persons is not much different
than the national average of 1 PT for every 2,500 persons.
However, there has been uneven growth across the state both in
the absolute numbers of physical therapists (see Exhibit 4) and in
numbers of PTs per population (see Exhibit 5).
PTs are more likely than PTAs to be recruited from across the
state, as well as from other states, but their employment location
post graduation may cluster in the counties where educational
institutions are located. Thus, the counties where PT schools are
located show the highest ratio of 3.53 or more active PTs per
10,000 population in 1998 in the entire state. Exhibit 9 displays
variation in active PT-per-population ratio and the location of PT
programs.
2.3 TRENDS IN PERSONNEL SUPPLY:
PHYSICAL THERAPIST ASSISTANTS
Physical therapist assistants in North Carolina are an impor-tant
part of the health care team, and their numbers have grown
dramatically over the last two decades (see Exhibit 6). In 1979,
there were only 208 active PTAs licensed in the state; over the
next ten years the number grew to 494. In 1998, the number of
PTAs was 1,430. During the 1980s the average annual rate of
growth in PTA supply was approximately 9 percent per year. The
growth rate during the 1990s was approximately 13 percent per
year, with most of this growth occurring in the most recent years.
However, there has been uneven growth across the state both in
the absolute numbers of physical therapist assistants (see Exhibit
7) and in numbers of PTAs per population (see Exhibit 8).
The typical location of employment for PTAs is close to their
training site. Students enrolled in PTA programs are generally
being recruited from communities near the campus and are seek-ing
employment opportunities in the same or similar nearby com-munities.
Exhibit 10 displays variation in the active PTAs-per-population
ratio and the location of PTA programs.
Little is known about the long-term workforce participation
of PTAs over their life span, so future projections about their
availability and/or their utilization can only be speculative.
Further, we do not have a clear impression about whether or not
future plans of these educational institutions are in the direction
of expansion, contraction, or stability. Finally, we are not aware of
any plans to initiate programs at other educational institutions or
to close existing ones. Therefore, our projections assumed stability
in the number of graduates, the site of their education, and the
deployment and retention of their graduates.
2.4 SUPPLY OF PTAS RELATIVE TO PTS.
Physical therapist assistants may play an important role in
extending physical therapy services to a larger population than
can be reached by physical therapists alone, and most national
and local estimates project a more rapid increase in PTA jobs than
for PT jobs. Hence, one important consideration in understanding
workforce dynamics in the supply of physical therapy personnel is
the ratio of PTAs to PTs. Nationally, PTA/PT ratio was .28 in 1995,
and it was expected to increase to nearly .50 in 2005, and to over
.60 in 2020. In North Carolina, the ratio of PTA to PTs rose from
0.31 in 1979 to 0.37 in 1989. It has risen even more rapidly dur-ing
the 1990s, and for the most recent year (1998) stands at 0.51.
Although the number of physical therapists graduating annually in
North Carolina is higher than the number of physical therapist
assistants, the in-state retention of PTAs is substantially higher
than that of PTs, leading to an increase in the PTA to PT ratio.
2.5 TRENDS IN THE DISTRIBUTION OF PHYSICAL THERAPY
PERSONNEL ACROSS NORTH CAROLINA
In this section we examine the question of the distribution of
physical therapy personnel across the state and the extent to
which differential distribution of the workforce represents a health
policy concern. Both the regional and rural-urban distribution of
physical therapy personnel are far from uniform across the state
(see Exhibits 4, 5 and 9 for PT distribution in North Carolina).
As is typical of all health professionals, the highest absolute and
relative numbers of PTs are in the state’s urban areas and in areas
where per capita income is the highest. These are also areas where
other health professionals, notably physicians, are more likely to
be present. Thus in the Wake, Mountain, and Greensboro AHEC
areas the availability of PTs approximates 1 for every 2,000 per-sons.
On the other hand, in Area L, Eastern, and Southern
Regional AHEC, the population to PT ratio exceeds 3,000:1. The
distribution of PTAs, on the other hand, seems to reflect a differ-ent
pattern with higher numbers and densities in areas near train-ing
institutions that are located in nonmetropolitan areas (see
Exhibits 7, 8 and 10 for PTA distribution in North Carolina).
Three of the four AHEC areas with the highest PTA-to-population
ratios are largely rural: Mountain AHEC, Area L AHEC, and
Coastal AHEC. On the other hand, Greensboro and Wake AHECs
seem to have lower than the state average of PTAs-per-population
suggesting that in these areas, PTAs are not substituting for PTs.
When the PT and PTA workforce is broken down by metro-politan
and non-metropolitan areas, an interesting trend emerges
(see Exhibit 11). The ratio of PTs to PTAs has remained relatively
constant in metropolitan areas over the last 20 years, ranging
around 0.4 PTAs per PT. In the state’s non-metro areas, however,
PTAs have grown steadily relative to PTs. Consequently, there are
now about 0.8 PTAs for every PT in the state’s nonmetropolitan
counties.
The geographic distribution of PTs and PTAs also differs by
whether or not a county is a federally designated Health
Professional Shortage Area (HPSA). Those counties that are whole
county HPSAs tend to have fewer physical therapists, and also
have fallen further behind as the growth of PT supply has escalat-ed
(both absolutely and relatively) in the more prosperous, more
urbanized counties. Thus, HPSA designated counties currently
have about 1.2 PTs per 10,000 population while the remaining
counties have about 4.0 PTs per 10,000 which is approximately at
the national average (see Exhibit 12). The trends in geographic
distribution of PTAs are somewhat different than for PTs. Growth
in PTAs has occurred most especially since 1993 and has occurred
both in HPSA counties and in other counties. There are currently
about 1.2 PTAs per 10,000 population in HPSA counties, which is
approximately the same as the ratio of PTs per 10,000 population
in those same counties. The remaining counties have a ratio of
about 2.0 PTAs per 10,000 population (see Exhibit 13).
2.6 WORKFORCE DIVERSITY
Given a steady growth in the physical therapy workforce, the
panel thought it important to examine the extent to which the
diversity of this workforce matches the diversity of North
Carolina’s current and future population. Using the self-stated race
on the licensure forms for 1996, 1997, and 1998, we estimated
the number of individuals in the PT and PTA by race.
Traditionally under-represented minorities in the health profes-sions
are not well represented in North Carolina’s physical therapy
workforce (see Exhibit 14 for ethnic composition of North
Carolina’s physical therapy workforce and general population in
1998). For example, only 4.2 percent of individuals in the PT
workforce identified themselves as Black, American Indian, or
Asian. Although this proportion has increased recently from 3.9
percent in 1996, it is still small when compared with a 1998 esti-mated
statewide population which contains 26.5 percent minori-ties.
About 2 percent of the physical therapist workforce is African
American compared with approximately 22 percent of the overall
population in North Carolina. The diversity of the physical thera-pist
assistant workforce is somewhat greater. In 1998, nonwhite
PTAs constituted about 8.9 percent of the workforce. This per-centage
is down slightly from the previous two years: 9.5 percent
(1997); 9.2 percent (1996). Further, despite a growing Hispanic
population in North Carolina, there are no reliable data on
Hispanic ethnicity of PTs and PTAs nor on the linguistic compe-tence
of these professionals.
III. Conclusions
3.1 SUPPLY AND DISTRIBUTION OF PHYSICAL THERAPY
PERSONNEL.
The data provided here do not suggest that there is a sub-stantial
surplus of physical therapists in North Carolina, nor that
such a surplus situation is likely to occur in the near term given
the continuation of current trends in North Carolina’s production
of physical therapists. However, the situation does bear continued
monitoring as the traditional signposts of a shortage are no longer
present.
The supply of, and requirements for, physical therapists
seem to be in balance at this time. Hence, the current situation
does not warrant implementing any rapid major changes in the
state’s educational policy at this time. The overall supply of physi-cal
therapists is slightly below the national ratios, approximates
the national average in urban areas, and is substantially below the
national ratios in the traditionally underserved health professions
shortage areas of the state. The state’s urban areas may have
reached a saturation point, but there is room for improvement
elsewhere, assuming employment opportunities can be developed.
At the same time, it does not appear that physical therapists are
becoming increasingly more likely to practice in rural areas, or in
the less economically developed regions of the state, especially in
the eastern part of the state.
More systematic data collection on the physical therapy
workforce employment situation should be conducted by
requesting this information directly from individuals on the
annual re-licensure survey. Tabulation and dissemination of this
information can help identify imbalances and fine tune any
state policy decisions or actions in a more timely and objective
manner.
3.2 THE IMPORTANCE OF PHYSICAL THERAPIST ASSISTANTS
IN THE WORKFORCE
Much of the expansion and extension of physical therapy
services to the less urban, more isolated, and less economically
developed regions of the state appears to have been provided
through the use physical therapist assistants. The existing system
of education through community colleges appears to have largely
achieved its objective of the extension of PTA services into more
remote areas of the state. However, this process may be reaching a
limit if sufficient numbers of PTs are not available in these com-munities
to supervise the PTAs living and working in these com-munities.
However, no change in the educational policies with
respect to the PTA programs seems warranted without a more sys-tematic
vision of the future utilization of these personnel. We have
not examined retention or workforce participation of PTAs over
their life cycle but clearly such information will be required if we
are to have better information in order to plan for the preparation
of these health professionals over a longer time horizon.
3.3 ISSUES OF DIVERSITY IN THE WORKFORCE
Despite a steady growth in the PT workforce, the diversi-ty
of that workforce does not match the diversity of North
Carolina’s current or future population. Traditionally under repre-sented
minorities in the health professions are not well represent-ed
in North Carolina’s physical therapy workforce. For example,
only 4.2 percent of the PT workforce and 8.9 percent of the phys-ical
therapy assistant workforce is nonwhite (i.e., African
American, Asian, or Native American.). In comparison, the state’s
general population is 26.5% nonwhite. It is worth noting that the
diversity of the physical therapist assistant workforce is somewhat
greater than that of the PT workforce. Further, there is a higher
representation of minorities in the PTA workforce in the two
AHEC regions of the state where more than one third of the gen-eral
population is nonwhite (Area L and Eastern AHEC).
The problem of under-representation of the state’s largest
ethnic minority, African Americans, in the health professions is
long-standing and is by no means limited to physical therapy.
However, this traditional challenge is compounded by new demo-graphic
trends. The ever increasing diversity of the population of
North Carolina now includes growing numbers of individuals
with Asian and Hispanic origin. Many of these individuals may
face linguistic isolation and pose special cultural challenges for the
physical therapy workforce in the coming years. The task force is
unaware of data describing health professionals’ linguistic compe-tencies
in North Carolina. Further, although there has been much
discussion of cultural competencies in educational circles, little is
known about how efforts to develop such competencies play out
in actual practice.
3.4 ISSUES OF DATA AND MEASUREMENT OF CHANGES
IN THE WORKFORCE
More systematic data collection about the employment situa-tion
of physical therapy practitioners should be conducted by
requesting this information directly from individuals on the annu-al
re-licensure survey. Timely tabulation and dissemination of this
information can help identify imbalances and should increase the
effectiveness with which decision makers can “fine-tune” the edu-cational
and other workforce policies. As objective data are accu-mulated,
ongoing analyses of trends might minimize the tendency
for various stakeholders to overreact to transient events. Thus a
solid database should enable all stakeholders to better distinguish
short-term fluctuations in demand occasioned by changes in
employment levels or reimbursement policies from underlying
long term trends that may require more deliberate or decisive
intervention.
The North Carolina Board of Physical Therapy has taken a
step forward by adding questions about current workforce partici-pation
and workforce intentions to its annual relicensure survey.
The panel made use of preliminary releases of these data to guide
its deliberations. In particular, the panel’s efforts to calculate the
unemployment rate for PTs and PTAs and to identify the extent to
which individuals were not renewing their licenses relied on these
data (data not reported in this report since it is in the preliminary
stage of analysis). These figures seemed to be relatively low and
comparable to national data provided by the APTA. However, the
most effective and promising use of these data are still ahead of
us; as more meaningful interpretation will require ongoing data
compilation, refinement and analysis of trend data.
IV. Recommendations
SUPPLY AND EDUCATION
The panel concludes that supply and requirements in the
physical therapy professions are in approximate balance at this
time and recommends the following courses of action to educa-tional
institutions in North Carolina preparing physical therapy
personnel:
• Maintain the status quo with respect to the number of pro-grams
and the number of enrollments in physical therapy and
physical therapist assistants in North Carolina’s PT and PTA
programs. Follow the APTA suggested moratorium on any
new programs through 2003.
• Address the issue of under-representation of minorities in
physical therapist and physical therapist assistant programs in
North Carolina.
• Educational policy makers should avoid downsizing or clos-ing
programs in response to a single year’s decline in the
applicant pool or graduates’ employment opportunities.
Doing so might waste resources if demand resurfaces while
the capacity to produce new personnel is eroded. Hence, the
panel recommends that those few programs experiencing
declining enrollments should receive continued support for a
minimum of 3 to 5 years as local, state and national trends
can be observed and interpreted.
DISTRIBUTION
The panel acknowledges that geographic disparities in the
availability of physical therapy personnel exist throughout the
state and recommends the following policies:
• Continue to assess trends in geographic disparities but aug-ment
this information with more focused assessment of the
nature and extent of employment opportunities for graduates
that are available both in rural and in health professions
shortage areas.
• Oppose legislative initiatives which might inhibit patients
from having direct access to physical therapy practitioners
because such efforts might well discourage PT practice in
physician shortage areas.
DIVERSITY
The panel recommends that representatives of a diverse
community of stakeholders from the educational, professional,
regulatory, and employer communities should meet to frankly
address the lack of diversity in North Carolina’s PT workforce and
assess what specific strategies can be designed and implemented
to enable the ethnic composition of NC PT and PTA workforce to
more closely approach that of North Carolina’s general population.
The agenda of this group should include efforts to:
• develop an effective strategy to monitor admission, matricula-tion,
graduation, and initial employment data at both PT and
PTA programs for their size and diversity;
• monitor shifts in affirmative action policies affecting the
health professions at the national and state level;
• enlarge and develop the applicant pool and foster the recruit-ment
and retention of minority candidates to physical thera-pist
and physical therapist assistant educational institutions;
• assure that there are adequate employment opportunities for
minority physical therapists and physical therapist assistants,
especially in health professions shortage areas; and
• assess the success of educational programs in historically
minority colleges and universities and in other post-second-ary
education locations in the recruitment and retention of
minority students.
WORKFORCE SURVEILLANCE
The panel recommends that the following activities be
undertaken by the panel itself and other partners in the Allied
Health community.
Convene the expert panel annually to analyze workforce
supply data using a three-year time horizon. The timing of this
meeting should be determined in consultation with AHEC person-nel,
the Council for Allied Health in North Carolina, educational
program directors, and the licensing board. It should be strategi-cally
timed, late enough in the “licensing cycle” to acquire and
analyze latest available workforce data, but early enough in the
“educational planning” cycle to provide meaningful input into that
process. In addition, the panel recommends that in the interim a
regular one-hour time be scheduled every three months for an
optional meeting at which panel members can share information
and updates on PT/PTA workforce issues via a conference call.
The panel endorses efforts by the licensure board, the Cecil
G. Sheps Center for Health Services Research, and Area Health
Education Centers Program to enhance the collection and analysis
of data on several crucial workforce supply issues. These issues
include changes in the overall supply of licensees, the number res-ident
in the state, and number working in the state. The panel
encourages these organizations to work together to focus attention
on transitions involving attrition from, and accessions to, the
workforce. The panel will work with these organizations to devel-op
a specific data analysis protocol to facilitate year to year com-parisons
of the overall supply of workforce and of key transitions
in the workforce supply. To facilitate interpretation, the panel rec-ommends
that this protocol, once developed, be applied retro-spectively
to the previous three years’ databases to reflect three-year
trends to facilitate five-year forward projections. Key ele-ments
in that protocol should include:
• attrition measured in terms of: (a) withdrawals from licensed
practice (b) retirements;
• accessions broken down by: (a) in-migrants previously
licensed in another state; (b) initial licensees in NC coming
from out of state educational institution; (c) initial licensees
in NC coming from in-state program.
The panel endorses ongoing efforts to monitor geographic
trends in supply including county county-level ratios, under-rep-resentation
of minorities, urban versus rural differences, and
AHEC regions. The panel endorses ongoing efforts to monitor the
requirements for physical therapy personnel insofar as possible
both in terms of need and demand and recognizes that need is
likely to be relatively stable while demand can be quite volatile.
Need is largely driven by slowly varying and relatively predictable
underlying demographics and disease patterns, while demand can
shift quickly depending on scope of coverage and reimbursement
levels, and administrative decisions.
The panel recognizes both the utility of periodic surveys of
employers about demand for selected allied health professionals
and the costs and challenges that such data collection efforts
involve. It will explore the feasibility of more selective and effi-cient
survey mechanisms in subsequent annual meetings.
Graduating class size and expected additions to physical therapist workforce from in-state educational institutions: North Carolina, 1996-2003
Graduating class size Expected additions to NC workforce
Educational Institution 1996 1997 1998 1999 2000
Retention
factor* 1998 1999 2000 2001 2002 2003
Duke 30 30 29 29 29 0.17 5.0 5.0 5.0 5.0 5.0 5.0
East Carolina 35 48 47 47 47 0.60 28.0 28.0 28.0 28.0 28.0 28.0
UNC-CH 28 38 36 37 37 0.58 21.0 21.5 21.5 21.5 21.5 21.5
Western Carolina 0 0 29 31 31 0.59 17 18.2 18.2 18.2 18.2 18.2
Winston Salem State 18 18 17 17 17 0.82 14.0 14.0 14.0 14.0 14.0 14.0
Elon College 0 0 0 0 44 0.34 0.0 0.0 15.0 15.0 15.0 15.0
Total 111 134 158 161 205 85.0 86.7 101.7 101.7 101.7 101.7
* The retention factor is the proportion of graduates from 1998 classes actually holding licenses in and having a work address in North Carolina in 1999.
Year 2000+ estimates assume that the class size and retention rate is constant with historical trends. This factor is applied prospetively to anticipated
Sources: American Medical Association Allied Health databases, North Carolina Health Professions Data System and interviews with Elon College and
Winston Salem State University officials.
EXHIBIT 1
graduating class size to estimate new NC workforce entrants.
EXHIBIT 2
Graduating class size and expected additions to physical therapist assistant workforce from in-state educational institutions: North Carolina, 1996-2003
Graduating class size Expected additions to NC workforce
Educational Institution 1996 1997 1998 1999 2000
Retention
factor* 1998 1999 2000 2001 2002 2003
Stanly Community College 15 21 19 17 17 0.74 14.0 12.5 13.3 13.3 13.3 13.3
Central Peidmont Community College 0 0 21 21 21 0.81 17.0 17.0 17.0 17.0 17.0 17.0
Fayetteville Technical Community College 14 14 13 15 15 0.54 7.0 8.1 7.5 7.5 7.5 7.5
Caldwell Community College and Technical Institute 24 0 20 20 20 1.00 20.0 20.0 20.0 20.0 20.0 20.0
Nash Community College 18 13 13 12 12 0.85 11.0 10.2 10.6 10.6 10.6 10.6
Southwestern Community College 15 15 14 11 11 0.86 12.00 9.4 10.7 10.7 10.7 10.7
Martin Community College 23 21 20 19 19 0.7 14.00 13.3 13.7 13.7 13.7 13.7
Guilford Technical Community College 0 0 0 12 11 1.00 0 12 11 12 12 12
Total 109 84 120 127 126 95.0 102.5 103.8 104.8 104.8 104.8
Several other community colleges offer PTA training program through agreements with other educational institutions.
Sources: American Medical Association Allied Health databases, North Carolina Health Professions Data System and interviews with Guilford Technical Community College officials.
* The retention factor is the proportion of graduates from 1998 classes actually holding licenses in and having a work address in North Carolina in 1999.
Year 2000+ estimates assume that the class size and retention rate is constant with historical trends. This factor is applied prospetively to anticipated
graduating class size to estimate new NC workforce entrants.
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physical therapists.
Physical Therapists 1979, 1989, 1998, North Carolina
42
118
62
110
20 20
142
68
95
73
214
131
225
48 44
271
133
186 196
428
285
473
138
76
536
255
438
0
100
200
300
400
500
600
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC region
Number of Physical Therapists
Number of Active PTs, 1979 (Total in NC = 677)
Number of Active PTs, 1989 (Total in NC = 1335)
Number of Active PTs, 1998 (Total in NC = 2815)
EXHIBIT 4
Number of Physical Therapists per 10,000 Population,
US and NC, 1979 to 1998
2.3
3.6
4.0
4.0
4.4
4.9
4.4
4.0
1.2
1.3
1.4 1.4
1.5
1.7 1.7
2.0
2.2
2.4
2.6
2.6
3.0
3.2
3.5
3.3
4.0
1.7
1.9
1.2
3.6
3.7
1
2
3
4
5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapists Per 10,000 Population
US PTs
NC PTs
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active physical therapists
EXHIBIT 3
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physicial therapists.
Physical Therapists per 10,000 population for 1979, 1989 and 1998 in North Carolina
0.67
1.60
1.33
1.14
0.79 0.76
2.04
0.93 0.88
1.07
2.62 2.59
2.01
1.67 1.60
3.10
1.61 1.66
2.46
4.62
5.00
3.56
3.94
2.64
4.81
2.86
3.31
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC Region
Physical Therapists per 10,000 Population
1979 Ratio of PTs per 10,000 population (Statewide ratio = 1.16)
1989 Ratio of PTs per 10,000 population (Statewide ratio = 2.03)
1998 Ratio of PTs per 10,000 population (Statewide ratio = 3.73)
EXHIBIT 5
Number of Physical Therapist Assistants per
10,000 Population, NC, 1979 to 1998
0.4
0.4
0.5 0.5 0.6
0.6 0.6
0.8
0.8
0.9
1.1
1.1
1.4
1.6
1.8
0.6
0.7
0.4
1.9 1.9
.0
.5
1.0
1.5
2.0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapist Assistants Per 10,000 Population
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active physical therapy assistants
EXHIBIT 6
Source: North Carolina Health Professions Data System 1979, 1989 and 1998.
Figures include all licensed active physical therapist assistants.
Physical Therapist Assistants 1979, 1989, 1998, North Carolina
20
11
25
73
13
2
22
8
34
73
37 40
137
25 21
42 44
75
143
90
164
349
70 68
128
163
255
0
100
200
300
400
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC region
Number of Physical Therapist Assistants
1979 Number of Active PTA in North Carolina (Total in NC = 208)
1989 Number of Active PTA in North Carolina (Total in NC = 494)
1998 Number of Active PTA in North Carolina (Total in NC = 1430)
EXHIBIT 7
Physical Therapist Assistants per 10,000 population for 1979, 1989 and 1998 in North Carolina
0.32
0.15
0.54
0.76
0.51
0.08
0.32
0.11
0.32
1.07
0.45
0.79
1.22
0.87
0.76
0.48 0.53
0.63
1.89
0.97
2.88
2.63
2.00
2.36
1.15
1.83
1.92
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC Region
Physical Therapist Assistants per 10,000 Population
Ratio of PTAs per 10,000 population 1979 (Statewide ratio = 0.36)
Ratio of PTAs per 10,000 population 1989 (Statewide ratio = 0.75)
Ratio of PTAs per 10,000 population 1998 (Statewide ratio = 1.89)
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physical therapist assistants.
EXHIBIT 8
Active Physical Therapists per 10,000 Population, 1998
Location of Physical Therapy Training Programs
EXHIBIT 9
Active Physical Therapist Assistants per 10,000 Population, 1998
EXHIBIT 10
Location of Physical Therapy Training Programs
Physical Therapist Assistants per Physical Therapist, North Carolina
0.0
0.2
0.4
0.6
0.8
1.0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapist Assistants per Physical Therapist
Metropolitan
Non-Metropolitan
EXHIBIT 11
Physical Therapists per 10,000 Population Grouped by Health
Professions Shortage Area (HPSA) Status, North Carolina, 1979 to 1998
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapists per 10,000
Not a HPSA
Full County HPSA
Partial County HPSA
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active in-state non-federal Physical Therapists
Source for Health Professionals Shortage Areas:
Department of Health and Human Services, HRSA, Federal
Register: Dec. 31, 1996, Vol 61, No. 251
EXHIBIT 12
Physical Therapist Assistants per 10,000 Population Grouped by Health
Professions Shortage Area (HPSA) Status, North Carolina, 1979 to 1998
0
0.5
1
1.5
2
2.5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapy Assistants per 10,000
Not a HPSA
Full County HPSA
Partial County HPSA
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active in-state non-federal Physical Therapy Assistants
Source for Health Professionals Shortage Areas:
Department of Health and Human Services, HRSA, Federal
Register: Dec. 31, 1996, Vol 61, No. 251
EXHIBIT 13
EXHIBIT 14
Ethnic composition of North Carolina’s Physical Therapy Workforce and General Population, 1998
Percent Nonwhite*
AHEC region Physical Therapists Physical Therapist Assistants General Population
Southern 8.1 18.9 39.7
Greensboro 4.7 10.0 22.9
Mountain 1.7 2.4 7.0
Charlotte 5.1 9.2 22.5
Coastal 3.6 7.1 24.0
Area L 4.0 17.7 45.4
Wake 4.3 10.9 28.3
Eastern 3.5 9.2 30.8
Northwest 3.0 3.5 13.2
Entire State 4.2 8.9 24.1
* Individuals identifying themselves as Black make up 93% of nonwhite PTAs and 57% of nonwhite PTs. The remaining practitioners in the
nonwhite category are Asians (N=58), and American Indians (N=3) In addition to whites, the three remaining groups: other (N=8), Spanish
origin (N=12) and unknown or missing (N=41). Total Physical therapists, 1998 = 2815, Total number of physical therapist assistants, 1998 =
1430.
Sources: NC Health Professions Data System, 1998 and the US Bureau of the Census.
Figures include all licensed, active, physical therapists and physical therapist assistants.

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Maintaining Balance:
The Physical Therapy Workforce
in North Carolina in the Year 2000
REPORT OF THE TECHNICAL PANEL ON THE PHYSICAL THERAPY WORKFORCE
Presented to:
THE COUNCIL FOR ALLIED HEALTH IN NORTH CAROLINA
May, 2000
The Physical Therapy Workforce
Assessment Project is a joint effort of:
The Council for Allied Health in North Carolina
The North Carolina Area Health Education Centers Program
The Cecil G. Sheps Center for Health Services Research, UNC-Chapel Hill
Practitioners
Jan Gwyer, PT PhD
Department of Physical Therapy
Duke University Medical Center
Box 3965Durham, NC 27710
919-681-4381
Eileen Watkins, PT
President, NC PTA
CompRehab of Wilson
1811 Forest Hills Road
Wilson, NC 27893
252-243-7400
crwwilson@aol.com
Cathy Smith, PT
Department of Physical Therapy
Wake Medical Center
3000 New Bern Ave
Raleigh, NC 27610
919-852-3500
cathy.smith@wakemed.org
Carolyn Cusic, PT
NC Association for Home Care
908 Grove Street
Chapel Hill, NC 27514
(919) 929-5537
carolyncu@aol.com
Employers
Jim Sawyer
Summit–Inn at the Ridge
100 Riceville Rd.
Asheville, NC 28805
828-299-1110
Joan Evans, PT, MBA
Vice President, Moses Cone Memorial Hospital
1200 North Elm Street
Greensboro, NC 27401-1020
(336) 832-8243
joan.evans@mosescone.com
Ron Covington,
Medical Facilities of North Carolina
1300 S. Mint St. Ste. 201
Charlotte, NC 28203
704-338-5855
Educators
Katherine White, PT, PhD
Dept. of Physical Therapy
Western Carolina University
Cullowhee, NC 28723
(828) 227-2191
kwhite@wcu.edu
Darlene Sekerak, PT, PhD
Division of Physical Therapy
Dept. of Allied Health Sciences
CB #7135, Med School Wing E
University of North Carolina at Chapel Hill
Chapel Hill, NC 27599-7135
919-843-8660
dsekerak@css.unc.edu
Stephen Bailey, PT, PhD
Dept. of Physical Therapy
Campus Box 2085
Elon College
NC 27244-2010
(336) 538-6853
baileys@elon.edu
Workforce Planning Experts
Jackie Keener, PhD
Labor Market Information Division
NC Department of Labor
700 Wade Ave.
Raleigh, NC 27611
919-733-2936
Keener.Jackie@esc.state.nc.us
Ben Massey, PT
NC Board of PT Examiners
18W Colony Place, Suite 120
Durham, NC 27705
bfmassey@mindspring.com
Karen Haas, PT, MPH
NC Department of Health and Human Services
943 Washington Square Mall
Washington, NC 27889
(252) 946-6481 ext 293
Facilitators and other Attendees
Robert Thorpe, EdD, RT
Allied Health Sciences
UNC-CH, CB#7120
Chapel Hill, NC 27599-7120
(919) 966-2343
bthorpe@med.unc.edu
Alan Brown, MSW
NC AHEC Program
UNC-CH, CB#7165
Chapel Hill, NC 27599-7165
(919) 966-0814
albr@med.unc.edu
Thomas Konrad, PhD
Cecil G.Sheps Center for Health Services
Research
UNC-CH, CB#7590
Chapel Hill, NC 27599-7590
(919) 966-7636
bob_konrad@unc.edu
Samruddhi Thaker, MHA
Sheps Center for Health Services Research
UNC-CH, CB#7590
Chapel Hill, NC 27599-7590
(919) 966-4505
sthaker@email.unc.edu
Rees Jenkins, MBA
NC Health Care Facilities Association
Director, Policy Development
5109 Bur Oak Circle
Raleigh, NC 27612
(919) 782-3827
reesj@nchcfa.org
North Carolina Physical Therapy Workforce Assessment Technical Panel
Panel staff: Thomas Konrad, Johanna Ames, Carolyn Busse,Jean Cox, Erin Fraher, Tonya Jenkins, Michael Pirani, Jeff Rosenthal, Thomas Ricketts, Laura
Smith, Samruddhi Thaker and staff at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill.
Acknowledgements: The panel members would like to thank the North Carolina Area Health Education Centers, The Cecil G. Sheps Center for Health
Services Research and the Council for Allied Health in North Carolina for their vision for conducting this panel process. The study has been made possi-ble
by the financial support of the North Carolina Area Health Education Centers Program.
Executive Summary
Background
A proposal to establish an advisory panel to examine the
status of various North Carolina allied health professions was pre-sented
by The Cecil G. Sheps Center for Health Services Research
to the North Carolina Area Health Education Centers Program
(NC AHEC) and the Council for Allied Health in North Carolina
(Council) in March 1999. The purpose of the advisory panel
process was to review the best available statistical and administra-tive
data, to discuss existing and emerging policies, and to con-struct
a consensus statement on the need for, and supply of, allied
health professionals by selected disciplines in North Carolina. The
process was approved and designed as a collaborative effort by the
representatives of the Cecil G. Sheps Center for Health Services
Research, the Council and the NC AHEC. The process envisioned
a series of panels comprised of stakeholders including practition-ers,
employers, educators, and workforce planning experts for
each allied health profession. Physical therapy was selected as the
first profession under review and this document reports the
results of the consensus process.
A physical therapy panel was convened on November 17,
1999. The task before the panel was to address one overarching
question: “What is the overall balance between supply and require-ments
for physical therapists (PTs) and physical therapist assistants
(PTAs), and how is it likely to change given current trends?” Relatively
good data describing the supply of PTs and PTAs are available
through the North Carolina Health Professions Data System
(HPDS) maintained by the Cecil G. Sheps Center in collaboration
with the NC AHEC. These data provided the basis for the panel’s
examination of historic trends in the supply of PTs and PTAs.
Historically, the physical therapy occupation in North
Carolina has been believed to be in either a shortage or balance
situation when compared with the demand for physical therapy
services. Several indicators including the ratio of PTs per popula-tion,
the number of applicants for the employment positions, and
the reports of educational program directors, and growing salaries
have supported this belief. More recently, anecdotal reports of cut-backs
in hours and employment for physical therapists have
become widespread since the phase in of changes to the Medicare
program in the long-term care and rehabilitation systems required
by the Balanced Budget Act (BBA) of 1997. Although systematic
data were not always available or analyzed to quantify or validate
these views, the panel process undertaken as part of the collabora-tive
effort was able to systematically analyze and evaluate the PT
workforce situation in North Carolina.
Based on the data analyzed by the advisory panel and pre-sented
at length in this report, the panel makes the following rec-ommendations:
Recommendations
SUPPLY and EDUCATION
The panel concludes that supply and requirements in the
physical therapy professions are in approximate balance at this
time and recommends the following courses of action to educa-tional
institutions in North Carolina preparing physical therapy
personnel:
• Maintain the status quo with respect to the number of pro-grams
and the number of enrollments in physical therapy and
physical therapist assistants in North Carolina’s PT and PTA
programs. Follow the APTA suggested moratorium on any
new programs through 2003.
• Address the issue of under-representation of minorities in
physical therapist and physical therapist assistant programs in
North Carolina.
• Educational policy makers should avoid downsizing or clos-ing
programs in response to a single year’s decline in the
applicant pool or graduates’ employment opportunities.
Doing so might waste resources if demand resurfaces while
the capacity to produce new personnel is eroded. Hence, the
panel recommends that those few programs experiencing
declining enrollments should receive continued support for a
minimum of 3 to 5 years as local, state and national trends
can be observed and interpreted.
DISTRIBUTION
The panel acknowledges that geographic disparities in the
availability of physical therapy personnel exist throughout the
state and recommends the following policies:
• Continue to assess trends in geographic disparities but aug-ment
this information with more focused assessment of the
nature and extent of employment opportunities for graduates
that are available both in rural and in health professions
shortage areas.
• Oppose legislative initiatives which might inhibit patients
from having direct access to physical therapy practitioners
because such efforts might well discourage PT practice in
physician shortage areas.
DIVERSITY
The panel recommends that representatives of a diverse
community of stakeholders from the educational, professional,
regulatory, and employer communities should meet to frankly
address the lack of diversity in North Carolina’s PT workforce and
assess what specific strategies can be designed and implemented
to enable the ethnic composition of NC PT and PTA workforce to
more closely approach that of North Carolina’s general population.
The agenda of this group should include efforts to:
• develop an effective strategy to monitor admission, matricula-tion,
graduation, and initial employment data at both PT and
PTA programs for their size and diversity;
• monitor shifts in affirmative action policies affecting the
health professions at the national and state level;
• enlarge and develop the applicant pool and foster the recruit-ment
and retention of minority candidates to PT and PTA
educational institutions;
• assure that there are adequate employment opportunities for
minority physical therapists and physical therapist assistants,
especially in health professions shortage areas; and
• assess the success of educational programs in historically
minority colleges and universities and in other post-second-ary
education locations in the recruitment and retention of
minority students.
WORKFORCE SURVEILLANCE
The panel recommends that the following activities be
undertaken by the panel itself and other partners in the Allied
Health community.
Convene the expert panel annually to analyze workforce
supply data using a three-year time horizon. The timing of this
meeting should be determined in consultation with AHEC person-nel,
the Council, educational program directors, and the licensing
board. It should be strategically timed, late enough in the “licens-ing
cycle” to acquire and analyze latest available workforce data,
but early enough in the “educational planning” cycle to provide
meaningful input into that process. In addition, the panel recom-mends
that in the interim a regular one-hour time be scheduled
every three months for an optional meeting at which panel mem-bers
can share information and updates on PT/PTA workforce
issues via a conference call.
The panel endorses efforts by the licensure board, the Cecil
G. Sheps Center for Health Services Research, and NC AHEC to
enhance the collection and analysis of data on several crucial
workforce supply issues. These issues include changes in the over-all
supply of licensees, the number residing and the number
working in the state. The panel encourages these organizations to
work together to focus attention on transitions involving attrition
from, and accessions to, the physical therapy workforce. The
panel will work with these organizations to develop a specific data
analysis protocol to facilitate year to year comparisons of the over-all
supply of workforce and of key transitions in the workforce
supply. To facilitate interpretation, the panel recommends that this
protocol once developed be applied retrospectively to the previous
three years’ data to facilitate five-year forward projections. Key
elements in that protocol should include:
• attrition measured in terms of: (a) withdrawals from
licensed practice (b) retirements;
• accessions broken down by: (a) in-migrants previously
licensed in another state; (b) initial licensees in NC coming
from out of state educational institution; (c) initial
licensees in NC coming from in-state program.
The panel endorses ongoing efforts to monitor geo-graphic
trends in supply including county level ratios,
under-representation of minorities, urban versus rural differ-ences,
and AHEC regions. The panel endorses ongoing
efforts to monitor the requirements for physical therapy per-sonnel
insofar as possible both in terms of need and
demand and recognizes that need is likely to be relatively
stable while demand can be quite volatile. Need is largely
driven by slowly varying and relatively predictable underly-ing
demographics and disease patterns, while demand can
shift quickly depending on scope of coverage and reim-bursement
levels, and administrative decisions.
The panel recognizes both the utility of periodic sur-veys
of employers about demand for selected allied health
professionals and the costs and challenges that such data
collection efforts involve. It will explore the feasibility of
more selective and efficient survey mechanisms in subse-quent
annual meetings.
I. Background
1.1 THE PHYSICAL THERAPY WORKFORCE IN TRANSITION
For the 10 year period from 1996 to 2006, the US Bureau of
Labor Statistics has predicted that the supply of physical thera-pists
in the United States will increase from 115,000 to 196,000
and that physical therapist assistants will increase from 84,000 to
151,000. Despite these predictions, this strong growth may not be
realized due to changes in the way in which physical therapists
are reimbursed and because of changes in federal health insurance
programs. Anecdotal reports of cutbacks in hours and employ-ment
for physical therapists have become widespread since the
phase in of changes to the Medicare program in the long-term
care and rehabilitation systems required by the Balanced Budget
Act (BBA) of 1997. Because private insurers often follow
Medicare’s lead in coverage limitations and service exclusions, the
BBA provisions may have wider implications for the financing of
physical therapy and related services. Specifically, according to an
employment survey released in December, 1999 by the American
Physical Therapy Association (APTA), physical therapists who
work in skilled nursing facilities (SNFs), home health settings,
and in private practice continued to experience job losses, salary
cuts and reductions in practice hours. However, this survey
reported an unemployment rate of 3.2 percent, which was up just
slightly from the 3 percent unemployment rate reported in an
April 1999 APTA survey. There have been anecdotal reports by the
directors of educational programs for physical therapists and
physical therapist assistants about declines in employment
prospects for recent graduates.
More recent developments may have also affected the out-look
for physical therapy nationally. On November 9, 1999,
Congress passed the Balanced Budget Refinement Act (BBRA) that
mandates a two-year moratorium on the $1,500 Medicare pay-ment
cap on physical therapy and other rehabilitation services
which was included in the BBA of 1997. This new legislation was
signed into law on November 29, 1999 with an implementation
date of February 1, 2000. This law increases payment for services
provided in skilled nursing facilities to patients who have medical-ly
complex conditions; it also delays a previously scheduled 15
percent cut in payment for home health services until one year
after the implementation of a prospective payment system (PPS).
This development is likely to result in some improvement in the
outlook for the profession in the very near future. A notice in the
Federal Register [April 11, 2000] made it clear that physical thera-py
services are not part of the outpatient hospital PPS and that
Medicare will continue to pay for physical therapy services under
the fee schedule in all settings. This rule becomes effective in
October 2000. The PPS for rehabilitation hospitals is scheduled
for implementation on April 1, 2001 and is likely to affect the
physical therapy profession.
Despite the concerns associated with federal payment policies,
recent assessments of the balance between supply and requirements
for physical therapy occupations have either assumed labor short-ages,
a balanced employment situation, or only a slight labor sur-plus.
However, the possibility of a significant decrease in demand
for physical therapy services provides an important context in
which to focus attention on the physical therapy workforce. It is
possible that reductions driven by national reimbursement policies
may reverberate through local employers and may lead to underem-ployment
or unemployment of physical therapy personnel.
This possible scenario was an important consideration moti-vating
various stakeholders to approach the Council for Allied
Health in North Carolina and ask that a study be conducted to
assess the physical therapy workforce in the state.
1.2 THE ALLIED HEALTH WORKFORCE PLANNING PROCESS
A proposal to establish an advisory panel to examine the sta-tus
of various North Carolina allied health professions was pre-sented
to the North Carolina Area Health Education Centers
Program (NC AHEC) and the Council for Allied Health in North
Carolina (Council) in March 1999. The purpose of the proposed
panel process was to review the best available statistical and
administrative data, discuss existing and emerging policies, and to
construct a consensus statement on the need for, and supply of,
allied health professionals in selected disciplines in North
Carolina. The process was designed to take place under the joint
guidance of representatives of the Cecil G. Sheps Center, the
Council for Allied Health in NC and the Area Health Education
Centers Program. The process envisioned a series of panels com-posed
of representatives from various stakeholder groups.
Stakeholders included practitioners from the allied health profes-sions,
as well as employers, educators, and workforce planning
experts. Panels would be constructed to address the specific situa-tion
of different allied health professions over an extended time
period. The NC AHEC and the Council approved this proposal for
Allied Health in NC on April 27, 1999. Subsequently, the Council
for Allied Health in NC members debated which professions
would be selected for study over the next three years. Physical
therapy was selected as the first profession.
1.3 PHYSICAL THERAPY WORKFORCE TECHNICAL PANEL:
SCOPE OF WORK
A panel consisting of educators, practitioners and employers
was convened on November 17, 1999. The task before the panel
was to assess the employment conditions of physical therapists
and physical therapist assistants in the state of North Carolina. A
number of questions were raised:
• Are PTs and PTAs facing the same situation in North Carolina
as in the rest of the country?
• How well are the physical therapy needs of the North
Carolinians being met?
• Have the employment prospects of physical therapy person-nel
been reduced?
These questions can be subsumed under one general question:
What is the overall balance between supply and requirements for
physical therapists and physical therapist assistants, and how is it likely
to change given current trends?
At the state level, where educational and workforce policy
meet, one of the key issues involves answering the question: “Are
we producing too many, too few, or about the right number of
physical therapists and physical therapist assistants to meet cur-rent
and future requirements?”
Although the overall balance between supply and require-ments
is a paramount workforce issue, other concerns are equally
important. For example, some issues, such as staffing shortages,
recruitment and retention difficulties, and underemployment of
physical therapists and physical therapist assistants may be more
relevant for certain areas of the state or for certain specific stake-
holder groups. This is the case because North Carolina is a diverse
state with extensive geographic and demographic variability.
Concerns with distribution and diversity raise the following ques-tion:
“Are some areas of the state or population groups more
prone to experience certain kinds of labor imbalances such as
staffing shortages, recruitment and retention difficulties, or under-employment?”
The goal of this collaborative project was to examine the
forces affecting employment for physical therapists and physical
therapist assistants in North Carolina. The primary strategy was to
build the project on accepted workforce analysis methods and to
use the best available data to address the above questions. This
consensus statement is based on the data analysis and panel dis-cussion
concerning the current and likely future balance of supply
and requirements for physical therapists and physical therapist
assistants in the state of North Carolina.
The remainder of this report examines national trends in the
physical therapy workforce, provides background on the North
Carolina situation, describes the information and data sources that
the panel used, reports the panel’s findings and conclusions, and
ends with the panel’s recommendations.
NATIONAL TRENDS
In 1997, the APTA commissioned a workforce study
from Vector Research, Inc. to look at the employment prospects of
PTs and PTAs through the year 2020. Their methodology included
the examination of salaries and job vacancy rates and interviews
with program directors in educational institutions, recruiters, state
APTA representatives, researchers, and practicing PTs and PTAs.
Vector’s supply projections accounted for US and interna-tional
new entrants, deaths, retirements, and part-time labor force
participation. The demand forecasts used age-, sex-, and insur-ance-
adjusted per capita staffing models that reflect the current
paradigm of population-centered health care planning. The model
also incorporated factors such as the aging of the population,
long-term economic growth, and increased HMO penetration.
Finally, increased competition from other health care providers
(chiropractors, athletic trainers, and occupational therapists) was
also considered.
The Vector study projected that a national shortage of quali-fied
PTs would continue through 1998, at which point equilibri-um
would occur. By the year 2000, they projected a slight sur-plus.
According to this scenario, physical therapists would still be
able to find employment, but not in their most preferred employ-ment
setting or geographic location. The Vector Study projected
that new entrants into the field would increase due to both an
increasing number of educational programs and an in-migration
of foreign-educated PTs. Not until 2005 would there be a notice-able
decline in employment opportunities marked by lower real
compensation, lower rates of labor participation, and declining
enrollments in educational programs. A surplus of PTs on the
order of 20-30 percent would exist by 2005-2007.
On the supply side, Vector used conservative estimates of
new educational programs that yielded average annual increases in
new entrants of slightly more than 5 percent for PTs and 12 per-cent
for PTAs at the national level. On the demand side, PTs and
PTAs typically serve an older patient population that provides a
source of reimbursement at the most favorable rates. Vector
assumed that competitors such as chiropractors, occupational
therapists and athletic trainers would maintain a market share
similar to their current share. Technology would have a negligible
effect on the demand. They also stated that the demand for PTs
may decrease due to increased use of PTAs. Demand for PTs was
projected to decrease by 3 percent between 1995 and 2005.
Vector projected that demographic and economic factors
would each affect demand: an aging population would account for
a 12 percent increase and economic growth would account for an
additional 12 percent increase. The Vector study assumed that
growth in demand would be lessened through expansion of the
“California model” of managed care. This “California model” sug-gests
that managed care firms will lower expenses by limiting
patient visits to health professionals, in this case PTs and PTAs.
This service delivery policy was expected to account for an antici-pated
17 percent decrease in demand, while the substitution of
PTAs for PTs accounts for an additional 10 percent decrease in
demand for PTs. Taken together, Vector’s scenarios anticipated that
new demand for PTs or PTAs would be concentrated among ‘sec-ond-
choice’ settings like home health and nursing homes. The
introduction of the Balanced Budget Act of 1997 (subsequent to
the Vector Study) may change the applicability of this scenario. It
appears that underemployment (i.e., part-time personnel who
report working fewer hours than they want to) may actually be a
special characteristic of PTs and PTAs employed in skilled nursing
facilities and home health care settings.
Additionally, in the area of physical therapy educational pro-grams,
the Doctor of Physical Therapy (DPT) — a post baccalau-reate
degree offered upon successful completion of a doctoral-level
professional (entry-level) or a post-professional “transition” educa-tion
program– has recently been the focus of numerous questions
and concerns by physical therapists. Throughout the US, as of
April 1, 2000, eight professional DPT programs are accredited, 19
BSPT (Bachelors) or MPT (Masters) programs are making the tran-sition
to the DPT, and 3 institutions are developing professional
DPT programs.
As health care delivery becomes a global enterprise, both for-profit
and nonprofit organizations are making health care available
to people in developing and transitional countries in Africa, Asia
and Latin America. Globalization of the employment market is
likely to increase employment opportunities for physical therapists
and physical therapists assistants outside the United States and is
expected to affect the supply and demand scenario in the long run.
Finally, there has been an emerging interest in the area of
evaluating effectiveness of physical therapist interventions at the
national level. This interest is reflected by the six one-year research
grants awarded by the Foundation for Physical Therapy Board of
Trustees to fund research projects to evaluate the effectiveness of
physical therapist interventions in different practice areas.
II. The North Carolina Situation
Historically, the physical therapy occupation in North
Carolina has been believed to be in either a shortage or balance
situation when compared with the demand for physical therapy
services. This belief was supported by several indicators. First, the
supply of therapists per population has been below the national
average. Further, the number of applicants has far exceeded the
positions available, and the reports of physical therapy program
directors have consistently indicated that virtually all of their
graduates were being employed or seeking additional education.
Growing salaries and widespread reports that employers were
seeking to fill positions buttressed this widely shared belief,
although systematic data were not always available to quantify or
validate these perceptions.
Relatively good data describing the supply of PTs and PTAs
are available through the North Carolina Health Professions Data
System (HPDS). The HPDS is maintained by the Cecil G. Sheps
Center in collaboration with the North Carolina Health Education
Centers Program and contains data on many of North Carolina’s
licensed health professionals. The HPDS data facilitated the panel’s
ability to examine historic trends in the supply of physical thera-pists
and physical therapist assistants with a relatively high level
of precision. Early in the panel’s deliberations, panel members
realized that efforts to assess demand or requirements for PT serv-ices
are not very precise, and may require more sustained data
collection or the definition of more explicit assumptions. Existing
data in North Carolina’s license files report the settings in which
PTs and PTAs in North Carolina are currently working. These set-tings
include hospitals, nursing homes, home health agencies,
rehabilitation centers, physician offices, school systems, private
and contract practices, as well as faculty positions in educational
institutions. However, these data do not specify whether person-nel
are part or full time workers in these settings. The most recent
license renewal data collected in 1999 by the North Carolina
Physical Therapy Board contains this information and will prove
helpful in future workforce monitoring efforts. Unfortunately,
these 1999 data were not available to the panel during its deliber-ations
and therefore could not be included as part of supporting
evidence for this consensus statement.
One of the advantages of having licensure data is that infor-mation
is available on PTs and PTAs who are classified as inactive
within the state. It can also be ascertained year to year who does
not renew their license and thus, the supply numbers can be
adjusted with more precision. Because this workforce is a relative-ly
young one, it is not expected that retirements will be a major
factor in projecting the size of the workforce in the near term. It is
not presently known how extensive mid-career temporary with-drawal
is present among the physical therapy workforce, or how
frequently inactive PTs living in NC return to the workforce. Both
longitudinal analyses of licensure data, and ongoing work by
members of the panel in this area will be helpful in monitoring
the supply and demand of physical therapy professions. Analyses
of the most recent data from the NC licensure renewal form for
2000 is not reflected in this study.
Because the assumptions on the supply side of the Vector
study were either unstated or not applicable to North Carolina, we
chose a comparative approach. This involves benchmarking the
supply and requirements balance against national ratios. The first
order measure of “requirements” is a comparative practitioner-to-population
ratio where the primary standard is the national practi-tioner-
to-population ratio as defined by the APTA’s latest available
data. This ratio was compared to the North Carolina practitioner-to-
population ratio which was determined using the HPDS data.
Data from the HPDS files were analyzed at the Sheps Center dur-ing
June– November 1999 and a preliminary statement on the
state of physical therapy profession was drafted and disseminated
to members of the panel in March 2000.
2.1 THE CONTRIBUTION OF NORTH CAROLINA’S EDUCATIONAL
INSTITUTIONS TO THE OVERALL SUPPLY OF PHYSICAL
THERAPY PERSONNEL
A key issue for workforce planning in North Carolina relates
to the extent to which policies under the control of the state can
affect the size, composition, and distribution of the health care
workforce. The primary impact that state policy makers can have
on these factors is through support for educational institutions.
Consequently we have devoted a substantial portion of this report
to the discussion of this topic.
To understand the relationship between the output of North
Carolina’s educational institutions and new entrants in the work-force,
we have calculated an indicator called the “retention factor.”
This index is simply the proportion of graduates of schools locat-ed
in North Carolina who have obtained a license, kept that
license for one year, and who currently have a mailing address in
this state. For PTs statewide, the overall retention factor is about
0.54. This means that only slightly more than half of the PTs
trained in the state’s educational institutions can be expected to
enter the North Carolina PT workforce.
However, as can be seen from Exhibit 1, the retention factor
differs substantially by school and program. Private schools (e.g.,
Duke) tend to recruit a larger proportion of their applicants from
out of state and disperse these graduates quite widely geographi-cally.
The retention factor for Duke’s master’s degree program for
the 1998 graduating class was 0.17, meaning that only 17 percent
of those graduates are currently in the NC workforce. Studies of
employment of recent graduates in NC and adjoining states are
currently being conducted by Dr. Jan Gwyer and promise to yield
more information about this process.
The master’s degree programs at the three large state
schools– East Carolina University (Greenville), University of North
Carolina (Chapel Hill) and Western Carolina University
(Cullowhee) most likely recruit a larger proportion of in-state stu-dents
than programs at private colleges and universities. A rela-tively
uniform proportion of the graduates of each of these pro-grams–
almost 60 percent– enters the North Carolina workforce.
The retention profile of the state’s only bachelor’s level program,
Winston Salem State, is somewhat higher, with about 82 percent
of the school’s 1999 graduates entering in the North Carolina
workforce. Although the graduating class of this program is quite
small, its actual capacity exceeds the number graduating in recent
years. Because of the new requirement for postgraduate education,
the future contribution of this institution to the NC PT workforce
assumes that the proposed Master’s degree program will receive
provisional accreditation shortly and that 70 percent of 20 esti-mated
graduates will stay in state. This estimate is based on the
fact that 7 of the 10 students already admitted to that program are
North Carolina residents. Finally, we have included a projected
graduation class of 44 in our estimates from the state’s newest PT
program located at Elon College. We project that 15 of those grad-uates
(34 percent) will remain in state based on an informal poll
taken by the director of Elon College’s PT program. Our projec-tions
assume that the class size will remain constant for all these
programs.
This profile of the state’s graduates should be placed in the
context of the entire PT workforce. Historically, the growth of
North Carolina’s PT workforce has resulted more from in-migra-tion
than from production of graduates from the state’s schools.
Over the last decade, the average net annual growth in PTs has
averaged about 165 per year, but, assuming our retention figures
are correct, only about 66 per year of these new additions have
been due to production of graduates from the state’s schools. This
latter figure comes from applying the aggregate retention factor
(0.54) to the average of the 1996 and 1997 graduates. We do not
have graduation or retention figures before this period.
Although less than half of all new additions to the North
Carolina PT workforce are coming from in-state schools, the over-whelming
majority of that 50 percent are coming from the four
state-supported schools. Consequently, this is the place where
state-initiated activity might have its greatest impact on the PT
workforce. Comparison of the 1998 licensure file to the 1997 file
suggests that new licenses were granted to 317 individuals with
NC mailing addresses. Of these, only 81 were graduates of NC
schools, which is a number consistent with our expectations using
the data provided by the NC PT Board. However, the relatively
large number of new entrants into the state, compared to the
overall historic trend may need further examination. More analysis
of year-to-year differences in attrition and out-migration would be
worthwhile. It is not possible to compare 1999 addresses to 1998
addresses, because the 1999 data file is not yet available.
When the same type of analysis is applied to the physical
therapist assistant workforce, we find that the overall retention
factor is in the range of 0.75 (see Exhibit 2). Thus unlike physical
therapists, most of this growth has occurred as a result of the
activities of in-state educational institutions, mostly the publicly-supported
community college system. There are currently 8 wide-ly
dispersed community colleges that are educating PTA’s in two-year
programs; most of these typically accept a new class each
year. The total output of these programs has typically been about
100 to 120 graduates per year for the last four years. The Guilford
Technical Community College started in fall 1998 and is the most
recent PTA program. It offers training in cooperation with 7 other
community colleges and reserves slots for each of these colleges.
Further, since a high proportion of these individuals enter the NC
workforce, net additions to the workforce from in-state technical
and community college programs are in the range of 90 to 95 new
PTAs. One school, Fayetteville Technical Institute and Community
College located near a large military base, has approximately 54
percent of individuals who enter the NC workforce.
2.2 TRENDS IN PERSONNEL SUPPLY: PHYSICAL THERAPISTS
The growth in the number of physical therapists in the state
has been substantial over the last 20 years. North Carolina had
only 677 active physical therapists in 1979; a decade later that
number had almost doubled to 1,335, while by 1998 there were
2,815 PTs active in the state. Similarly, Exhibit 3 displays growth
in the ratio of PT per 10,000 population which has been substan-tial
and has increased over the last decade. In 1989 there were 2
PTs for every 10,000 persons in North Carolina. By 1998 this
ratio had become 3.7, approximating the national rates. According
to data from the American Physical Therapy Association, the
national ratio of PTs per 10,000 population has stabilized between
4.0 and 4.9 over the last decade, after a period of substantial
growth in the 1980s. Thus, North Carolina’s current ratio of about
1 physical therapist for every 2,700 persons is not much different
than the national average of 1 PT for every 2,500 persons.
However, there has been uneven growth across the state both in
the absolute numbers of physical therapists (see Exhibit 4) and in
numbers of PTs per population (see Exhibit 5).
PTs are more likely than PTAs to be recruited from across the
state, as well as from other states, but their employment location
post graduation may cluster in the counties where educational
institutions are located. Thus, the counties where PT schools are
located show the highest ratio of 3.53 or more active PTs per
10,000 population in 1998 in the entire state. Exhibit 9 displays
variation in active PT-per-population ratio and the location of PT
programs.
2.3 TRENDS IN PERSONNEL SUPPLY:
PHYSICAL THERAPIST ASSISTANTS
Physical therapist assistants in North Carolina are an impor-tant
part of the health care team, and their numbers have grown
dramatically over the last two decades (see Exhibit 6). In 1979,
there were only 208 active PTAs licensed in the state; over the
next ten years the number grew to 494. In 1998, the number of
PTAs was 1,430. During the 1980s the average annual rate of
growth in PTA supply was approximately 9 percent per year. The
growth rate during the 1990s was approximately 13 percent per
year, with most of this growth occurring in the most recent years.
However, there has been uneven growth across the state both in
the absolute numbers of physical therapist assistants (see Exhibit
7) and in numbers of PTAs per population (see Exhibit 8).
The typical location of employment for PTAs is close to their
training site. Students enrolled in PTA programs are generally
being recruited from communities near the campus and are seek-ing
employment opportunities in the same or similar nearby com-munities.
Exhibit 10 displays variation in the active PTAs-per-population
ratio and the location of PTA programs.
Little is known about the long-term workforce participation
of PTAs over their life span, so future projections about their
availability and/or their utilization can only be speculative.
Further, we do not have a clear impression about whether or not
future plans of these educational institutions are in the direction
of expansion, contraction, or stability. Finally, we are not aware of
any plans to initiate programs at other educational institutions or
to close existing ones. Therefore, our projections assumed stability
in the number of graduates, the site of their education, and the
deployment and retention of their graduates.
2.4 SUPPLY OF PTAS RELATIVE TO PTS.
Physical therapist assistants may play an important role in
extending physical therapy services to a larger population than
can be reached by physical therapists alone, and most national
and local estimates project a more rapid increase in PTA jobs than
for PT jobs. Hence, one important consideration in understanding
workforce dynamics in the supply of physical therapy personnel is
the ratio of PTAs to PTs. Nationally, PTA/PT ratio was .28 in 1995,
and it was expected to increase to nearly .50 in 2005, and to over
.60 in 2020. In North Carolina, the ratio of PTA to PTs rose from
0.31 in 1979 to 0.37 in 1989. It has risen even more rapidly dur-ing
the 1990s, and for the most recent year (1998) stands at 0.51.
Although the number of physical therapists graduating annually in
North Carolina is higher than the number of physical therapist
assistants, the in-state retention of PTAs is substantially higher
than that of PTs, leading to an increase in the PTA to PT ratio.
2.5 TRENDS IN THE DISTRIBUTION OF PHYSICAL THERAPY
PERSONNEL ACROSS NORTH CAROLINA
In this section we examine the question of the distribution of
physical therapy personnel across the state and the extent to
which differential distribution of the workforce represents a health
policy concern. Both the regional and rural-urban distribution of
physical therapy personnel are far from uniform across the state
(see Exhibits 4, 5 and 9 for PT distribution in North Carolina).
As is typical of all health professionals, the highest absolute and
relative numbers of PTs are in the state’s urban areas and in areas
where per capita income is the highest. These are also areas where
other health professionals, notably physicians, are more likely to
be present. Thus in the Wake, Mountain, and Greensboro AHEC
areas the availability of PTs approximates 1 for every 2,000 per-sons.
On the other hand, in Area L, Eastern, and Southern
Regional AHEC, the population to PT ratio exceeds 3,000:1. The
distribution of PTAs, on the other hand, seems to reflect a differ-ent
pattern with higher numbers and densities in areas near train-ing
institutions that are located in nonmetropolitan areas (see
Exhibits 7, 8 and 10 for PTA distribution in North Carolina).
Three of the four AHEC areas with the highest PTA-to-population
ratios are largely rural: Mountain AHEC, Area L AHEC, and
Coastal AHEC. On the other hand, Greensboro and Wake AHECs
seem to have lower than the state average of PTAs-per-population
suggesting that in these areas, PTAs are not substituting for PTs.
When the PT and PTA workforce is broken down by metro-politan
and non-metropolitan areas, an interesting trend emerges
(see Exhibit 11). The ratio of PTs to PTAs has remained relatively
constant in metropolitan areas over the last 20 years, ranging
around 0.4 PTAs per PT. In the state’s non-metro areas, however,
PTAs have grown steadily relative to PTs. Consequently, there are
now about 0.8 PTAs for every PT in the state’s nonmetropolitan
counties.
The geographic distribution of PTs and PTAs also differs by
whether or not a county is a federally designated Health
Professional Shortage Area (HPSA). Those counties that are whole
county HPSAs tend to have fewer physical therapists, and also
have fallen further behind as the growth of PT supply has escalat-ed
(both absolutely and relatively) in the more prosperous, more
urbanized counties. Thus, HPSA designated counties currently
have about 1.2 PTs per 10,000 population while the remaining
counties have about 4.0 PTs per 10,000 which is approximately at
the national average (see Exhibit 12). The trends in geographic
distribution of PTAs are somewhat different than for PTs. Growth
in PTAs has occurred most especially since 1993 and has occurred
both in HPSA counties and in other counties. There are currently
about 1.2 PTAs per 10,000 population in HPSA counties, which is
approximately the same as the ratio of PTs per 10,000 population
in those same counties. The remaining counties have a ratio of
about 2.0 PTAs per 10,000 population (see Exhibit 13).
2.6 WORKFORCE DIVERSITY
Given a steady growth in the physical therapy workforce, the
panel thought it important to examine the extent to which the
diversity of this workforce matches the diversity of North
Carolina’s current and future population. Using the self-stated race
on the licensure forms for 1996, 1997, and 1998, we estimated
the number of individuals in the PT and PTA by race.
Traditionally under-represented minorities in the health profes-sions
are not well represented in North Carolina’s physical therapy
workforce (see Exhibit 14 for ethnic composition of North
Carolina’s physical therapy workforce and general population in
1998). For example, only 4.2 percent of individuals in the PT
workforce identified themselves as Black, American Indian, or
Asian. Although this proportion has increased recently from 3.9
percent in 1996, it is still small when compared with a 1998 esti-mated
statewide population which contains 26.5 percent minori-ties.
About 2 percent of the physical therapist workforce is African
American compared with approximately 22 percent of the overall
population in North Carolina. The diversity of the physical thera-pist
assistant workforce is somewhat greater. In 1998, nonwhite
PTAs constituted about 8.9 percent of the workforce. This per-centage
is down slightly from the previous two years: 9.5 percent
(1997); 9.2 percent (1996). Further, despite a growing Hispanic
population in North Carolina, there are no reliable data on
Hispanic ethnicity of PTs and PTAs nor on the linguistic compe-tence
of these professionals.
III. Conclusions
3.1 SUPPLY AND DISTRIBUTION OF PHYSICAL THERAPY
PERSONNEL.
The data provided here do not suggest that there is a sub-stantial
surplus of physical therapists in North Carolina, nor that
such a surplus situation is likely to occur in the near term given
the continuation of current trends in North Carolina’s production
of physical therapists. However, the situation does bear continued
monitoring as the traditional signposts of a shortage are no longer
present.
The supply of, and requirements for, physical therapists
seem to be in balance at this time. Hence, the current situation
does not warrant implementing any rapid major changes in the
state’s educational policy at this time. The overall supply of physi-cal
therapists is slightly below the national ratios, approximates
the national average in urban areas, and is substantially below the
national ratios in the traditionally underserved health professions
shortage areas of the state. The state’s urban areas may have
reached a saturation point, but there is room for improvement
elsewhere, assuming employment opportunities can be developed.
At the same time, it does not appear that physical therapists are
becoming increasingly more likely to practice in rural areas, or in
the less economically developed regions of the state, especially in
the eastern part of the state.
More systematic data collection on the physical therapy
workforce employment situation should be conducted by
requesting this information directly from individuals on the
annual re-licensure survey. Tabulation and dissemination of this
information can help identify imbalances and fine tune any
state policy decisions or actions in a more timely and objective
manner.
3.2 THE IMPORTANCE OF PHYSICAL THERAPIST ASSISTANTS
IN THE WORKFORCE
Much of the expansion and extension of physical therapy
services to the less urban, more isolated, and less economically
developed regions of the state appears to have been provided
through the use physical therapist assistants. The existing system
of education through community colleges appears to have largely
achieved its objective of the extension of PTA services into more
remote areas of the state. However, this process may be reaching a
limit if sufficient numbers of PTs are not available in these com-munities
to supervise the PTAs living and working in these com-munities.
However, no change in the educational policies with
respect to the PTA programs seems warranted without a more sys-tematic
vision of the future utilization of these personnel. We have
not examined retention or workforce participation of PTAs over
their life cycle but clearly such information will be required if we
are to have better information in order to plan for the preparation
of these health professionals over a longer time horizon.
3.3 ISSUES OF DIVERSITY IN THE WORKFORCE
Despite a steady growth in the PT workforce, the diversi-ty
of that workforce does not match the diversity of North
Carolina’s current or future population. Traditionally under repre-sented
minorities in the health professions are not well represent-ed
in North Carolina’s physical therapy workforce. For example,
only 4.2 percent of the PT workforce and 8.9 percent of the phys-ical
therapy assistant workforce is nonwhite (i.e., African
American, Asian, or Native American.). In comparison, the state’s
general population is 26.5% nonwhite. It is worth noting that the
diversity of the physical therapist assistant workforce is somewhat
greater than that of the PT workforce. Further, there is a higher
representation of minorities in the PTA workforce in the two
AHEC regions of the state where more than one third of the gen-eral
population is nonwhite (Area L and Eastern AHEC).
The problem of under-representation of the state’s largest
ethnic minority, African Americans, in the health professions is
long-standing and is by no means limited to physical therapy.
However, this traditional challenge is compounded by new demo-graphic
trends. The ever increasing diversity of the population of
North Carolina now includes growing numbers of individuals
with Asian and Hispanic origin. Many of these individuals may
face linguistic isolation and pose special cultural challenges for the
physical therapy workforce in the coming years. The task force is
unaware of data describing health professionals’ linguistic compe-tencies
in North Carolina. Further, although there has been much
discussion of cultural competencies in educational circles, little is
known about how efforts to develop such competencies play out
in actual practice.
3.4 ISSUES OF DATA AND MEASUREMENT OF CHANGES
IN THE WORKFORCE
More systematic data collection about the employment situa-tion
of physical therapy practitioners should be conducted by
requesting this information directly from individuals on the annu-al
re-licensure survey. Timely tabulation and dissemination of this
information can help identify imbalances and should increase the
effectiveness with which decision makers can “fine-tune” the edu-cational
and other workforce policies. As objective data are accu-mulated,
ongoing analyses of trends might minimize the tendency
for various stakeholders to overreact to transient events. Thus a
solid database should enable all stakeholders to better distinguish
short-term fluctuations in demand occasioned by changes in
employment levels or reimbursement policies from underlying
long term trends that may require more deliberate or decisive
intervention.
The North Carolina Board of Physical Therapy has taken a
step forward by adding questions about current workforce partici-pation
and workforce intentions to its annual relicensure survey.
The panel made use of preliminary releases of these data to guide
its deliberations. In particular, the panel’s efforts to calculate the
unemployment rate for PTs and PTAs and to identify the extent to
which individuals were not renewing their licenses relied on these
data (data not reported in this report since it is in the preliminary
stage of analysis). These figures seemed to be relatively low and
comparable to national data provided by the APTA. However, the
most effective and promising use of these data are still ahead of
us; as more meaningful interpretation will require ongoing data
compilation, refinement and analysis of trend data.
IV. Recommendations
SUPPLY AND EDUCATION
The panel concludes that supply and requirements in the
physical therapy professions are in approximate balance at this
time and recommends the following courses of action to educa-tional
institutions in North Carolina preparing physical therapy
personnel:
• Maintain the status quo with respect to the number of pro-grams
and the number of enrollments in physical therapy and
physical therapist assistants in North Carolina’s PT and PTA
programs. Follow the APTA suggested moratorium on any
new programs through 2003.
• Address the issue of under-representation of minorities in
physical therapist and physical therapist assistant programs in
North Carolina.
• Educational policy makers should avoid downsizing or clos-ing
programs in response to a single year’s decline in the
applicant pool or graduates’ employment opportunities.
Doing so might waste resources if demand resurfaces while
the capacity to produce new personnel is eroded. Hence, the
panel recommends that those few programs experiencing
declining enrollments should receive continued support for a
minimum of 3 to 5 years as local, state and national trends
can be observed and interpreted.
DISTRIBUTION
The panel acknowledges that geographic disparities in the
availability of physical therapy personnel exist throughout the
state and recommends the following policies:
• Continue to assess trends in geographic disparities but aug-ment
this information with more focused assessment of the
nature and extent of employment opportunities for graduates
that are available both in rural and in health professions
shortage areas.
• Oppose legislative initiatives which might inhibit patients
from having direct access to physical therapy practitioners
because such efforts might well discourage PT practice in
physician shortage areas.
DIVERSITY
The panel recommends that representatives of a diverse
community of stakeholders from the educational, professional,
regulatory, and employer communities should meet to frankly
address the lack of diversity in North Carolina’s PT workforce and
assess what specific strategies can be designed and implemented
to enable the ethnic composition of NC PT and PTA workforce to
more closely approach that of North Carolina’s general population.
The agenda of this group should include efforts to:
• develop an effective strategy to monitor admission, matricula-tion,
graduation, and initial employment data at both PT and
PTA programs for their size and diversity;
• monitor shifts in affirmative action policies affecting the
health professions at the national and state level;
• enlarge and develop the applicant pool and foster the recruit-ment
and retention of minority candidates to physical thera-pist
and physical therapist assistant educational institutions;
• assure that there are adequate employment opportunities for
minority physical therapists and physical therapist assistants,
especially in health professions shortage areas; and
• assess the success of educational programs in historically
minority colleges and universities and in other post-second-ary
education locations in the recruitment and retention of
minority students.
WORKFORCE SURVEILLANCE
The panel recommends that the following activities be
undertaken by the panel itself and other partners in the Allied
Health community.
Convene the expert panel annually to analyze workforce
supply data using a three-year time horizon. The timing of this
meeting should be determined in consultation with AHEC person-nel,
the Council for Allied Health in North Carolina, educational
program directors, and the licensing board. It should be strategi-cally
timed, late enough in the “licensing cycle” to acquire and
analyze latest available workforce data, but early enough in the
“educational planning” cycle to provide meaningful input into that
process. In addition, the panel recommends that in the interim a
regular one-hour time be scheduled every three months for an
optional meeting at which panel members can share information
and updates on PT/PTA workforce issues via a conference call.
The panel endorses efforts by the licensure board, the Cecil
G. Sheps Center for Health Services Research, and Area Health
Education Centers Program to enhance the collection and analysis
of data on several crucial workforce supply issues. These issues
include changes in the overall supply of licensees, the number res-ident
in the state, and number working in the state. The panel
encourages these organizations to work together to focus attention
on transitions involving attrition from, and accessions to, the
workforce. The panel will work with these organizations to devel-op
a specific data analysis protocol to facilitate year to year com-parisons
of the overall supply of workforce and of key transitions
in the workforce supply. To facilitate interpretation, the panel rec-ommends
that this protocol, once developed, be applied retro-spectively
to the previous three years’ databases to reflect three-year
trends to facilitate five-year forward projections. Key ele-ments
in that protocol should include:
• attrition measured in terms of: (a) withdrawals from licensed
practice (b) retirements;
• accessions broken down by: (a) in-migrants previously
licensed in another state; (b) initial licensees in NC coming
from out of state educational institution; (c) initial licensees
in NC coming from in-state program.
The panel endorses ongoing efforts to monitor geographic
trends in supply including county county-level ratios, under-rep-resentation
of minorities, urban versus rural differences, and
AHEC regions. The panel endorses ongoing efforts to monitor the
requirements for physical therapy personnel insofar as possible
both in terms of need and demand and recognizes that need is
likely to be relatively stable while demand can be quite volatile.
Need is largely driven by slowly varying and relatively predictable
underlying demographics and disease patterns, while demand can
shift quickly depending on scope of coverage and reimbursement
levels, and administrative decisions.
The panel recognizes both the utility of periodic surveys of
employers about demand for selected allied health professionals
and the costs and challenges that such data collection efforts
involve. It will explore the feasibility of more selective and effi-cient
survey mechanisms in subsequent annual meetings.
Graduating class size and expected additions to physical therapist workforce from in-state educational institutions: North Carolina, 1996-2003
Graduating class size Expected additions to NC workforce
Educational Institution 1996 1997 1998 1999 2000
Retention
factor* 1998 1999 2000 2001 2002 2003
Duke 30 30 29 29 29 0.17 5.0 5.0 5.0 5.0 5.0 5.0
East Carolina 35 48 47 47 47 0.60 28.0 28.0 28.0 28.0 28.0 28.0
UNC-CH 28 38 36 37 37 0.58 21.0 21.5 21.5 21.5 21.5 21.5
Western Carolina 0 0 29 31 31 0.59 17 18.2 18.2 18.2 18.2 18.2
Winston Salem State 18 18 17 17 17 0.82 14.0 14.0 14.0 14.0 14.0 14.0
Elon College 0 0 0 0 44 0.34 0.0 0.0 15.0 15.0 15.0 15.0
Total 111 134 158 161 205 85.0 86.7 101.7 101.7 101.7 101.7
* The retention factor is the proportion of graduates from 1998 classes actually holding licenses in and having a work address in North Carolina in 1999.
Year 2000+ estimates assume that the class size and retention rate is constant with historical trends. This factor is applied prospetively to anticipated
Sources: American Medical Association Allied Health databases, North Carolina Health Professions Data System and interviews with Elon College and
Winston Salem State University officials.
EXHIBIT 1
graduating class size to estimate new NC workforce entrants.
EXHIBIT 2
Graduating class size and expected additions to physical therapist assistant workforce from in-state educational institutions: North Carolina, 1996-2003
Graduating class size Expected additions to NC workforce
Educational Institution 1996 1997 1998 1999 2000
Retention
factor* 1998 1999 2000 2001 2002 2003
Stanly Community College 15 21 19 17 17 0.74 14.0 12.5 13.3 13.3 13.3 13.3
Central Peidmont Community College 0 0 21 21 21 0.81 17.0 17.0 17.0 17.0 17.0 17.0
Fayetteville Technical Community College 14 14 13 15 15 0.54 7.0 8.1 7.5 7.5 7.5 7.5
Caldwell Community College and Technical Institute 24 0 20 20 20 1.00 20.0 20.0 20.0 20.0 20.0 20.0
Nash Community College 18 13 13 12 12 0.85 11.0 10.2 10.6 10.6 10.6 10.6
Southwestern Community College 15 15 14 11 11 0.86 12.00 9.4 10.7 10.7 10.7 10.7
Martin Community College 23 21 20 19 19 0.7 14.00 13.3 13.7 13.7 13.7 13.7
Guilford Technical Community College 0 0 0 12 11 1.00 0 12 11 12 12 12
Total 109 84 120 127 126 95.0 102.5 103.8 104.8 104.8 104.8
Several other community colleges offer PTA training program through agreements with other educational institutions.
Sources: American Medical Association Allied Health databases, North Carolina Health Professions Data System and interviews with Guilford Technical Community College officials.
* The retention factor is the proportion of graduates from 1998 classes actually holding licenses in and having a work address in North Carolina in 1999.
Year 2000+ estimates assume that the class size and retention rate is constant with historical trends. This factor is applied prospetively to anticipated
graduating class size to estimate new NC workforce entrants.
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physical therapists.
Physical Therapists 1979, 1989, 1998, North Carolina
42
118
62
110
20 20
142
68
95
73
214
131
225
48 44
271
133
186 196
428
285
473
138
76
536
255
438
0
100
200
300
400
500
600
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC region
Number of Physical Therapists
Number of Active PTs, 1979 (Total in NC = 677)
Number of Active PTs, 1989 (Total in NC = 1335)
Number of Active PTs, 1998 (Total in NC = 2815)
EXHIBIT 4
Number of Physical Therapists per 10,000 Population,
US and NC, 1979 to 1998
2.3
3.6
4.0
4.0
4.4
4.9
4.4
4.0
1.2
1.3
1.4 1.4
1.5
1.7 1.7
2.0
2.2
2.4
2.6
2.6
3.0
3.2
3.5
3.3
4.0
1.7
1.9
1.2
3.6
3.7
1
2
3
4
5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapists Per 10,000 Population
US PTs
NC PTs
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active physical therapists
EXHIBIT 3
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physicial therapists.
Physical Therapists per 10,000 population for 1979, 1989 and 1998 in North Carolina
0.67
1.60
1.33
1.14
0.79 0.76
2.04
0.93 0.88
1.07
2.62 2.59
2.01
1.67 1.60
3.10
1.61 1.66
2.46
4.62
5.00
3.56
3.94
2.64
4.81
2.86
3.31
0.00
1.00
2.00
3.00
4.00
5.00
6.00
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC Region
Physical Therapists per 10,000 Population
1979 Ratio of PTs per 10,000 population (Statewide ratio = 1.16)
1989 Ratio of PTs per 10,000 population (Statewide ratio = 2.03)
1998 Ratio of PTs per 10,000 population (Statewide ratio = 3.73)
EXHIBIT 5
Number of Physical Therapist Assistants per
10,000 Population, NC, 1979 to 1998
0.4
0.4
0.5 0.5 0.6
0.6 0.6
0.8
0.8
0.9
1.1
1.1
1.4
1.6
1.8
0.6
0.7
0.4
1.9 1.9
.0
.5
1.0
1.5
2.0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapist Assistants Per 10,000 Population
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active physical therapy assistants
EXHIBIT 6
Source: North Carolina Health Professions Data System 1979, 1989 and 1998.
Figures include all licensed active physical therapist assistants.
Physical Therapist Assistants 1979, 1989, 1998, North Carolina
20
11
25
73
13
2
22
8
34
73
37 40
137
25 21
42 44
75
143
90
164
349
70 68
128
163
255
0
100
200
300
400
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC region
Number of Physical Therapist Assistants
1979 Number of Active PTA in North Carolina (Total in NC = 208)
1989 Number of Active PTA in North Carolina (Total in NC = 494)
1998 Number of Active PTA in North Carolina (Total in NC = 1430)
EXHIBIT 7
Physical Therapist Assistants per 10,000 population for 1979, 1989 and 1998 in North Carolina
0.32
0.15
0.54
0.76
0.51
0.08
0.32
0.11
0.32
1.07
0.45
0.79
1.22
0.87
0.76
0.48 0.53
0.63
1.89
0.97
2.88
2.63
2.00
2.36
1.15
1.83
1.92
0.00
0.50
1.00
1.50
2.00
2.50
3.00
3.50
Southern
Regional
Greensboro Mountain Charlotte Coastal Area L Wake Eastern Northwest
AHEC Region
Physical Therapist Assistants per 10,000 Population
Ratio of PTAs per 10,000 population 1979 (Statewide ratio = 0.36)
Ratio of PTAs per 10,000 population 1989 (Statewide ratio = 0.75)
Ratio of PTAs per 10,000 population 1998 (Statewide ratio = 1.89)
Source: North Carolina Health Professions Data System, 1979, 1989 and 1998.
Figures include all licensed active physical therapist assistants.
EXHIBIT 8
Active Physical Therapists per 10,000 Population, 1998
Location of Physical Therapy Training Programs
EXHIBIT 9
Active Physical Therapist Assistants per 10,000 Population, 1998
EXHIBIT 10
Location of Physical Therapy Training Programs
Physical Therapist Assistants per Physical Therapist, North Carolina
0.0
0.2
0.4
0.6
0.8
1.0
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapist Assistants per Physical Therapist
Metropolitan
Non-Metropolitan
EXHIBIT 11
Physical Therapists per 10,000 Population Grouped by Health
Professions Shortage Area (HPSA) Status, North Carolina, 1979 to 1998
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapists per 10,000
Not a HPSA
Full County HPSA
Partial County HPSA
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active in-state non-federal Physical Therapists
Source for Health Professionals Shortage Areas:
Department of Health and Human Services, HRSA, Federal
Register: Dec. 31, 1996, Vol 61, No. 251
EXHIBIT 12
Physical Therapist Assistants per 10,000 Population Grouped by Health
Professions Shortage Area (HPSA) Status, North Carolina, 1979 to 1998
0
0.5
1
1.5
2
2.5
1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
Year
Physical Therapy Assistants per 10,000
Not a HPSA
Full County HPSA
Partial County HPSA
Sources: North Carolina Health Professions Data System, 1979 to 1998;
HRSA, Bureau of Health Professions; US Bureau of the Census;
North Carolina Office of State Planning
Figures include all licenced active in-state non-federal Physical Therapy Assistants
Source for Health Professionals Shortage Areas:
Department of Health and Human Services, HRSA, Federal
Register: Dec. 31, 1996, Vol 61, No. 251
EXHIBIT 13
EXHIBIT 14
Ethnic composition of North Carolina’s Physical Therapy Workforce and General Population, 1998
Percent Nonwhite*
AHEC region Physical Therapists Physical Therapist Assistants General Population
Southern 8.1 18.9 39.7
Greensboro 4.7 10.0 22.9
Mountain 1.7 2.4 7.0
Charlotte 5.1 9.2 22.5
Coastal 3.6 7.1 24.0
Area L 4.0 17.7 45.4
Wake 4.3 10.9 28.3
Eastern 3.5 9.2 30.8
Northwest 3.0 3.5 13.2
Entire State 4.2 8.9 24.1
* Individuals identifying themselves as Black make up 93% of nonwhite PTAs and 57% of nonwhite PTs. The remaining practitioners in the
nonwhite category are Asians (N=58), and American Indians (N=3) In addition to whites, the three remaining groups: other (N=8), Spanish
origin (N=12) and unknown or missing (N=41). Total Physical therapists, 1998 = 2815, Total number of physical therapist assistants, 1998 =
1430.
Sources: NC Health Professions Data System, 1998 and the US Bureau of the Census.
Figures include all licensed, active, physical therapists and physical therapist assistants.